While entering data for a client in the EHR, the nurse uses NANDA International terminology to document which part of the nursing process?

• A. Diagnosis
• B. Planning
• C. Outcomes
• D. Interventions

Answer: (A)

Using NANDA International terminology aligns with documenting the nursing diagnosis, which is the diagnostic step in the nursing process. This standardized labeling names the client’s actual or potential problem based on the assessment, guiding subsequent planning, interventions, and evaluation. For example, a NANDA-I diagnosis like “Impaired gas exchange” would appear in the chart as the problem, and the plan would then specify goals and choose NIC interventions and NOC outcomes to address it. The planning, outcomes, and interventions themselves are documented with related frameworks after the diagnosis is established, so the NANDA-I term is specifically for the diagnostic part.