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Terms Used by Nurses to Describe Patient ProblemsCan SNOMED III represent nursing concepts in the patient record?

Terms Used by Nurses to Describe Patient ProblemsCan SNOMED III represent nursing concepts in the... Abstract Objective: To analyze the terms used by nurses in a variety of data sources and to test the feasibility of using SNOMED III to represent nursing terms. Design: Prospective research design with manual matching of terms to the SNOMED III vocabulary. Measurements: The terms used by nurses to describe patient problems during 485 episodes of care for 201 patients hospitalized for Pneumocystis carinii pneumonia were identified. Problems from four data sources (nurse interview, intershift report, nursing care plan, and nurse progress note/flowsheet) were classified based on the substantive area of the problem and on the terminology used to describe the problem. A test subset of the 25 most frequently used terms from the two written data sources (nursing care plan and nurse progress note/flowsheet) were manually matched to SNOMED III terms to test the feasibility of using that existing vocabulary to represent nursing terms. Results: Nurses most frequently described patient problems as signs/symptoms in the verbal nurse interview and intershift report. In the written data sources, problems were recorded as North American Nursing Diagnosis Association (NANDA) terms and signs/symptoms with similar frequencies. Of the nursing terms in the test subset, 69% were represented using one or more SNOMED III terms. This content is only available as a PDF. Author notes Supported by NR02215 from the National Center for Nursing Research. Dr. Campbell was supported by LM07033 from the National Library of Medicine. American Medical Informatics Association http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of the American Medical Informatics Association Oxford University Press

Terms Used by Nurses to Describe Patient ProblemsCan SNOMED III represent nursing concepts in the patient record?

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References (20)

Publisher
Oxford University Press
Copyright
American Medical Informatics Association
ISSN
1067-5027
eISSN
1527-974X
DOI
10.1136/jamia.1994.95236137
Publisher site
See Article on Publisher Site

Abstract

Abstract Objective: To analyze the terms used by nurses in a variety of data sources and to test the feasibility of using SNOMED III to represent nursing terms. Design: Prospective research design with manual matching of terms to the SNOMED III vocabulary. Measurements: The terms used by nurses to describe patient problems during 485 episodes of care for 201 patients hospitalized for Pneumocystis carinii pneumonia were identified. Problems from four data sources (nurse interview, intershift report, nursing care plan, and nurse progress note/flowsheet) were classified based on the substantive area of the problem and on the terminology used to describe the problem. A test subset of the 25 most frequently used terms from the two written data sources (nursing care plan and nurse progress note/flowsheet) were manually matched to SNOMED III terms to test the feasibility of using that existing vocabulary to represent nursing terms. Results: Nurses most frequently described patient problems as signs/symptoms in the verbal nurse interview and intershift report. In the written data sources, problems were recorded as North American Nursing Diagnosis Association (NANDA) terms and signs/symptoms with similar frequencies. Of the nursing terms in the test subset, 69% were represented using one or more SNOMED III terms. This content is only available as a PDF. Author notes Supported by NR02215 from the National Center for Nursing Research. Dr. Campbell was supported by LM07033 from the National Library of Medicine. American Medical Informatics Association

Journal

Journal of the American Medical Informatics AssociationOxford University Press

Published: Jan 1, 1994

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