ORIGINAL RESEARCH Identifying the barriers to use of standardized nursing language in the electronic health record by the ambulatory care nurse practitioner Dianne Conrad, DNP, RN, FNP-BC (Assistant Professor) 1, 2 , Patricia A. Hanson, PhD, RN, GNP (Professor) 2 , Susan M. Hasenau, PhD, RN, NNP-BC, CTN-A (Professor) 3 , & Julia Stocker-Schneider, PhD, RN (Associate Professor) 4 1 Kirkhof College of Nursing, Grand Valley State University, Grand Rapids, Michigan Cadillac Family Physicians, PC, Cadillac, Michigan 2 College of Nursing and Health, Madonna University, Livonia, Michigan 3 College of Nursing and Health, Madonna University, Livonia, Michigan 4 McAuley School of Nursing, University of Detroit Mercy, Detroit, Michigan Keywords Nurse practitioners; nurse practitioner communication; standardized nursing language; computers; electronic health records; electronic medical records. Correspondence Dianne Conrad, DNP, RN, FNP-BC, 4825 E. 32 RD, Cadillac, MI 49601. Tel: 231-920-7686; Fax: 231-775-2570; E-mail: conraddi@gvsu.edu Received: May 2011; accepted: December 2011 doi: 10.1111/j.1745-7599.2012.00705.x Abstract Purpose: This study identified the perceived user barriers to documentation of nursing practice utilizing standardized nursing language (SNL) in the electronic health record (EHR) by ambulatory care nurse practitioners (NPs). Data Sources: A researcher-developed survey was sent to a randomized sam- ple of ambulatory care NPs in the United States who belonged to the American Academy of Nurse Practitioners (n = 1997). Conclusions: Surveyed ambulatory care NPs placed a higher value on docu- menting medical care versus nursing care. Only 17% of respondents currently use SNL and 30% believe that SNL is not important or appropriate to document NP practice. Barriers to using SNL in EHRs included lack of reimbursement for nursing documentation, lack of time to document, and lack of availability of SNL in electronic records. Implications for Practice: Respondents identified NP practice as a blend of medical as well as nursing care but NPs have not embraced the current SNLs as a vehicle to document the nursing component of their care, particularly in EHRs. Until these barriers are addressed and discreet data in the form of SNL are available and utilized in the EHR, the impact of the NPs care will be unidentifiable for outcomes reporting. Nurse practitioners, electronic records, and standardized nursing language As the healthcare arena changes rapidly in the develop- ment and utilization of electronic medical records, there is an opportunity to enhance the visibility of advanced nursing practice and its impact on patient outcomes. The Initiative on the Future of Nursing (Institute of Medicine, 2011) highlights the importance of advanced practice nursing and information technology to meet present and future healthcare needs. Nurse practitioners (NPs) are continuing to fill primary care roles and manage not only chronic illnesses, but prevent acute care episodes and dis- ease. In order to meet these needs, NPs will increase the use of technological tools to aid in analysis and synthesis of information to improve the quality and effectiveness of care delivered to their patients. Electronic health records (EHRs) are one of the tools to manage the complexities of healthcare data. The Health Information Technology for Economic and Clin- ical Health Act (HITECH Act), passed in 2009, encour- aged healthcare organizations and providers to adopt and effectively utilize certified EHRs (Committee on Ways and Means, 2009). The HITECH Act outlines criteria to achieve “meaningful use” of certified electronic records. These criteria must be met in order for providers to receive financial incentives to promote adoption of EHRs as an integral part of their daily practice. 1 Journal of the American Academy of Nurse Practitioners 00 (2012) 1–9 C 2012 The Author(s) Journal compilation C 2012 American Academy of Nurse Practitioners