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Selecting a Standardized Terminology for the Electronic Health Record that Reveals the Impact of Nursing on Patient Care

By

Cynthia B. Lundberg, R.N., BSN; SNOMED Terminology Solutions; Judith J. Warren, PhD, RN, BC, FAAN, FACMI; University of Kansas; Jane Brokel, PhD, RN, NANDA International; Gloria M. Bulechek, PhD, RN, FAAN; Nursing Interventions Classification; Howard K. Butcher, PhD, RN, APRN, BC; Nursing Interventions Classification; Joanne McCloskey Dochterman, PhD, RN, FAAN; Nursing Interventions Classification; Marion Johnson, PhD, RN; Nursing Outcomes Classification; Meridean Maas PhD, RN; Nursing Outcomes Classification; Karen S. Martin, RN, NSN, FAAN; Omaha System; Sue Moorhead PhD, RN, Nursing Outcomes Classification; Christine Spisla, RN, MSN; SNOMED Terminology Solutions; Elizabeth Swanson, PhD, RN; Nursing Outcomes Classification, Sharon Giarrizzo-Wilson, RN, BSN/MS, CNOR, Association of PeriOperative Registered Nurses

Citation: Lundberg, C., Warren, J.., Brokel, J., Bulechek, G., Butcher, H., McCloskey Dochterman, J., Johnson, M., Mass, M., Martin, K., Moorhead, S., Spisla, C., Swanson, E., & Giarrizzo-Wilson, S. (June, 2008). Selecting a Standardized Terminology for the Electronic Health Record that Reveals the Impact of Nursing on Patient Care. Online Journal of Nursing Informatics (OJNI), 12, (2). Available at http:ojni.org/12_2/lundberg.pdf Page 2 of 20

Abstract Using standardized terminology within electronic health records is critical for nurses to communicate their impact on patient care to the multidisciplinary team. The universal requirement for quality patient care, internal control, efficiency and cost containment, has made it imperative to express nursing knowledge in a meaningful way that can be shared across disciplines and care settings. The documentation of nursing care, using an electronic health record, demonstrates the impact of nursing care on patient care and validates the significance of nursing practice. As key stakeholders of the American Nursing Association recognized terminologies, NANDA, NIC, NOC, Omaha System, PNDS, and SNOMED CT describe their respective classification systems to assist administrators, nursing executives, informatics nurses, nurse managers and staff nurses to make decisions concerning the selection of a nursing terminology or a combination of nursing terminologies that best meets their organizational needs.

Key Words: Nursing Terminology, Standardized nursing terminology, NANDA International, Nursing Intervention Classification (NIC), Nursing Outcome Classification (NOC), Omaha System, Perioperative Nursing Data Set (PNDS), and Systematized Nomenclature of Medicine (SNOMED CT) Introduction The care nurses provide to variety of care settings. Selecting the sustain life, enable recovery, appropriate nursing terminology alleviate suffering and promote implementation for use in the EHR health should be captured within the can be daunting. electronic health record (EHR). To This article will highlight share this information between selected American Nursing clinical disciplines and care settings, Association’s (ANA) recognized data needs to be recorded and stored nursing terminologies and their in a standardized form. relationships to each other. This Terminologies are one way to ensure discussion will assist in making standardization so patient care data decisions about the combination of can be stored in an unambiguous nursing terminologies that best fit way. Nursing has numerous your organization’s practice and terminologies, each developed for a requirements for the EHR.

Benefits of Implementing Standardized Terminologies within Electronic Health Records

Standardized nursing benefit by being able to measure terminologies provide benefits to nursing care and its impact on the patient, the organization, the patient care through queries of the nursing profession, and each patient record instead of costly country. Patients benefit from manual chart audits. This continuity of care being facilitated determination of nursing’s impact is through the use of standardized essential to validating the terminologies through improved contribution of nursing to and unambiguous communication healthcare and patient safety. between clinicians. Organizations Furthermore, the organization Page 3 of 20 benefits from the use of standard reveal the impact of nursing care terminologies by providing through electronic means (Weaver, administrators with the actual costs Warren, & Delaney, 2005). Each and benefits of nursing care. Then country benefits by having informed decisions can be made retrievable coded data that can be regarding staffing ratios. This aggregated into informative reports strategy has been useful for or data sets. These reports allow physicians using the Common countries to compare nursing’s Procedural Terminology (CPT contribution to care both nationally codes) for billing purposes and internationally using the (Giannangelo & Fenton, 2008). International Nursing Minimum Nurse educators use standardized Data Set. (Goosen, et al, 2006). terminologies in the curriculum to The standardized nursing teach nursing concepts that are terminologies, recognized by the critical in the nursing process and American Nursing Association are vital to developing new nurses (ANA), are the vehicles for the (Warren, Connors, & Weaver, aggregation of nursing data 2002). The registered nurse benefits recorded in EHRs which can be from the use of standardized used to improve quality of patient nursing terminologies to facilitate care and patient safety. critical thinking and decision Giannangelo and Fenton (2008) making at the point of care state that EHRs “must use (Dochterman, Titler, Wang, & consistent, codified terminology to Reed, 2005). The nursing eliminate ambiguity, confusion, and profession benefits from being ensure data correctness and provided a means to document, interoperability…standardized store, and retrieve evidence-based terminologies identify the discrete practice in a semantic way to structured data that allow data facilitate nursing research and capture and processing (p. 29).”

American Nursing Association Recognized Terminologies

The ANA Committee for vocabulary that supports nursing Nursing Practice Information and are clinically relevant for the Infrastructure (CNPII) has defined nursing domain. The terminologies specific criteria used to recognize need to possess clear and standardized terminologies. These unambiguous concepts with a criteria are foundational to the coding scheme containing one standardization of nursing unique identifier per concept. The documentation and verbal terminologies must contain communication that will lead to a documented testing of reliability, reduction in errors and an increase validity and clinical usefulness in in the quality and continuity of care practice to become recognized (American Nursing Association (American Nursing Association [ANA], 2006, 1). The ANA criteria [ANA], 2006, 1). The ANA require that terminologies possess recognized nursing terminologies Page 4 of 20

are listed in alphabetical order in Table 1.

Table 1: ANA recognized terminologies ANA Recognized Terminology URL Nursing Process Date Integrated Terminologies within Terminology Recognized by Within Other the ANA Terminologies CCC http://www.sabacare.com/ Diagnoses, Clinical Care Interventions, and Classification Outcomes ICNP International http://www.icn.ch/icnp.ht Diagnoses, Classification of m Interventions, and Nursing Practice Outcomes

NANDA www.nanda.org Nursing Diagnoses 1992 NLM- UMLS NANDA SNOMED CT International PNDS HL7 NIDSEC NIC www.nursing.uiowa.edu/c Interventions 1992 NLM- UMLS Nursing nc SNOMED CT Intervention HL7 Classification NIDSEC ABC Codes

NOC www.nursing.uiowa.edu/c Outcomes 1998 NLM- UMLS Nursing Outcome nc Indicators SNOMED CT Classification HL7 NIDSEC

Omaha System www.omahasystem.org Problem 1992 NLM- UMLS Classification Scheme SNOMED CT Intervention Scheme HL7 Problem Rating Scale NIDSEC for Outcomes LOINC ABC Codes PNDS www.aorn.org/PracticeRe Diagnoses, 1999 NLM- UMLS Perioperative sources/PNDS Interventions and SNOMED CT Nursing Data Set Outcomes HL7

SNOMED CT httpwww.cap.org/apps/ca Assessment concepts, 2002 NLM- UMLS Systematic p.portal? Diagnoses, Nomenclature of _nfpb=true&_pageLabel= Interventions, and Medicine Clinical snomed_page Outcomes Terms Page 5 of 20

Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT)

SNOMED CT is a concepts and relationships used comprehensive, scientifically precisely in recording and validated clinical terminology and representing clinical information infrastructure for healthcare across the scope of healthcare. containing a broad coverage of SNOMED CT is concept-based, terminology supporting healthcare meaning each concept has a distinct documentation through the definition and a unique code continuum of care. SNOMED CT identifier. SNOMED CT consists of provides a consistent way of 19 top-level hierarchies, e.g.: indexing, storing, retrieving and procedures (medical and surgical aggregating clinical data across procedures, laboratory and specialties and sites of care. The use radiology procedures, interventions, of SNOMED CT within electronic education and management health records provides interoperable procedures), clinical findings, data extraction and analysis that can (nursing diagnoses, disorders, be shared across clinicians, clinical diseases that are necessarily settings and organizations both abnormal, clinical observations and nationally and internationally. signs and symptoms) body SNOMED CT is in structures, observable entity conformance with National industry (concepts that represent questions regulatory standards and the being asked during an assessment), Consolidated Health Initiative devices, substances, and (CHI) [ONC, 2006]. The National medications. Committee on Vital and Health SNOMED CT hierarchies Statistics (NCVHS) in 2003 rated are created through defining SNOMED CT highest among all relationships linking one concept to terminologies evaluated for another concept for the purpose of electronic health record as it met defining each concept down to its the essential criteria defined specific meaning. Defining according to sound medical concepts by using parent-child informatics practices (SNOMED relationship begins to build vertical Terminology Solutions, SNOMED hierarchies within SNOMED CT. CT 2007). SNOMED CT is in Concepts lower in the hierarchy are compliance with allied standards by more specific in meaning then enabling SNOMED CT to concepts higher up in the hierarchy, effectively interoperate with other creating multiple levels of standards such as the International granularity. Defining relationship Standards Organization (ISO), attributes further defines the Health Language 7 (HL7) and concept’s meaning by relating all National Quality Forum (NQF). that is necessary and sufficient to SNOMED CT is a clinical fully represent the concept’s terminology comprised of codes, definition. Page 6 of 20

Table 2: SNOMED CT Example SNOMED CT Definition of chest pain Pain (finding) IsA Chest pain (finding) Finding Site: Thoracic structure (body structure) IsA Pain of truncal structure (finding) IsA Pain finding at anatomical site (finding) IsA Clinical finding (finding)

The way concepts are defined in SNOMED CT core, the SNOMED CT makes up its logical terminology developers validated concept definition the mappings to ensure accurate that is necessary to extract a robust representation of the nursing data aggregation used to support concepts and that the concepts were research and analysis. defined equivalently as represented Integration of the ANA within their terminology system. recognized standardized The ANA recognized terminologies within SNOMED nursing terminologies provide Reference Terminology (SNOMED nurse-sensitive terminology needed RT) began by collaborating with to encode the nursing domain. each of the nursing terminology SNOMED CT can be used to developers to ensure accurate encode nursing documentation of terminology representation. The the full healthcare encounter e.g.: SNOMED Nursing Working Group acute care, home care, hospice care, identified additional defining spiritual health, long-term care and relationships needed to define health care clinic visits. SNOMED concepts within the nursing domain. CT can be used to encode These defining relationships are assessments, flow-sheets, education consistent with the International plans, care plans, task lists and Standard Organization (ISO) Nursing nursing notes within the electronic Terminology Model Standard for health record. The ANA recognized diagnoses and interventions. terminologies that have been Once the ANA recognized integrated within SNOMED CT are terminologies were integrated presented in alphabetical order in within SNOMED RT, and before table 3. they were released within

Table 3: ANA Recognized Terminologies integrated within SNOMED CT ANA Recognized Data elements integrated Concepts in SNOMED Terminologies within SNOMED CT Hierarchies Clinical Care Diagnoses, Interventions Diagnoses – Clinical findings Classification (CCC) Interventions – Procedures International Diagnoses, Interventions, and Catalog Development Strategy in Classification of Nursing Outcomes Process Page 7 of 20

ANA Recognized Data elements integrated Concepts in SNOMED Terminologies within SNOMED CT Hierarchies Practice (ICNP) NANDA International Nursing diagnoses Diagnoses – Clinical findings (NANDA) Nursing Intervention Intervention labels Interventions – Procedures Classification (NIC) Nursing Outcome Outcome labels Outcome labels – Observable Classification (NOC) Entity

Omaha System Problem Classification scheme Problem Classification Scheme Intervention Scheme Problems and signs & symptoms—Clinical findings Intervention Scheme Procedures ---Procedures Peri-operative Nursing Diagnoses, Interventions, and Diagnoses – Clinical findings Data Set (PNDS) Outcomes Interventions – Procedures Outcomes – Clinical findings

NANDA International

NANDA diagnoses are used class; is a division of diagnostic to identify human responses to concepts by type of response risks, disease, injury or health (activity/exercise, behavior or promotion. The nurse uses a critical knowledge, healthcare system), and thinking process to diagnose these 3) nursing diagnosis defined as “a human responses. This involves clinical judgment about an interpretation of human behaviors individual, family or community related to patient, family or a responses to actual or potential community’s health. (Lunney, health problems/life processes” 2001). Nursing diagnoses in (NANDA, 2007, p 332). NANDA electronic health records provides International nursing diagnoses in the ability to select nursing an electronic healthcare record interventions to achieve outcomes provide a framework for nursing to for which a nurse is accountable document and state the priority (NANDA, 2005, p 277). NANDA needs and problems to address International nursing diagnoses within the health encounter whether have evolved from an alphabetical in the inpatient, ambulatory or listing in the mid 1970’s to a homecare/hospice setting. NANDA conceptual system that guide International nursing diagnoses are classification of nursing diagnoses used to develop problem lists, in a taxonomy. The structure of the assessments, plans of care and taxonomy has 3 levels, 1) domain; clinical pathways as a means to is an area of interest or study label patient conditions. (functional, physiological, Additionally, an electronic health psychosocial, environmental), 2) record developer adds the Page 8 of 20

definition, defining characteristics, while using the electronic health risk and related factors as record to guide the selection of an knowledge reference text for accurate diagnosis. students and novice nurses to access

Table 4: NANDA Nursing Diagnosis Example NANDA Nursing Diagnosis Ineffective breathing Risk for Falls Readiness for Enhanced pattern Knowledge Is an actual diagnostic -Is a risk diagnostic -Is a health promotion diagnostic concept within Domain 4: concept within Domain concept within Domain 5: Perception/ Activity/Rest under Class 4 11: Safety/Protection Cognition under Class 4: Cognition. Cardiovascular/Pulmonary under Class 2: Physical Responses Injury

Nursing Interventions Classification (NIC)

NIC is a comprehensive set with a definition and a unique of research-based nursing numeric code that can be used for interventions nurses perform. The reimbursement of nursing use of NIC facilitates the analysis interventions. The codes are used to of the impact of activities on patient facilitate computer use allowing outcomes. Nursing interventions are communication with other coded an integral part of the nursing systems, e.g. SNOMED CT, process focused on outcome NANDA and NOC. The NIC identification and evaluation. A taxonomy that describes the domain nursing intervention is defined as of nursing consists of 7 domains any treatment, based upon clinical and 30 classes. The NIC domains judgment and knowledge that a are illustrated in table 5. NIC can be nurse performs to enhance used in all clinical settings (from patient/client outcomes. Nursing acute care, intensive care units, to interventions include both direct home care, to hospice care, to long- and indirect care aimed at term care and to primary care) and individuals, families and the all specialties and has been community. The current NIC translated into Chinese, Dutch, edition (2008) has 542 interventions French, German, Portuguese, and more than 1200 activities. Each Japanese, Korean, and Spanish to intervention includes a label name support worldwide implementation. Page 9 of 20

Table 5: NIC 7 Domains Physiological: Basic Family Physiological: Complex Health System Behavioral Community Safety

The use of the NIC multidimensional scaling classification system in an (Bulechek, Butcher, & Dochterman, electronic health record facilitates 2008). These research methods are the appropriate selection of nursing complementary to NANDA and the interventions used to demonstrate Nursing Outcomes Classification. A the impact of nursing by major achievement of the research communicating nursing project has been the testing the interventions to other clinicians on usefulness of NIC and its the interdisciplinary healthcare implementation in growing team. A standardized nursing numbers of client populations, intervention enables researchers to information systems and examine the effectiveness and cost educational programs. The Center that can be used to allocate nursing for Nursing Classification and care. The use of standardized Clinical Effectiveness outlines nursing interventions in nursing research methods for retrieving education curricula facilitates the clinical nursing data from electronic teaching of clinical decision making systems, storing it according to to nurses at the point-of-care by privacy requirements, applying risk articulating the nursing process as it adjustment techniques, and is used in clinical practice. A large analyzing the impact of nursing research team has been working treatments (Dochterman, Titler, since 1987 to construct, validate, Wang, & Reed, 2005). and implement NIC as a NIC interventions are used standardized language for nursing in electronic health record interventions using a variety of implementation of plans of care, qualitative and quantitative critical pathways, order sets, patient methods including content analysis, education and data sets for the expert surveys, hierarchical analysis evaluation of care at the individual and or unit level.

Table 6: NIC example Intervention Selected Activities Pain Management Encourage patient to use adequate pain Definition: Alleviation of pain or a medication reduction in pain to a level of comfort that Explore patient’s knowledge and beliefs is acceptable to the patient. about pain Ensure that patient receives attentive analgesic care Teach about pharmacological methods of pain relief Page 10 of 20

Promote adequate rest/sleep to facilitate pain relief Use pain control measures before pain becomes severe

The Nursing Outcomes Classification (NOC)

Nurses have been NOC consists of outcomes documenting the outcomes of their for individual patients, families, and interventions for decades but the communities used across all clinical lack of common language and settings and specialties. NOC is associated measures for outcomes organized using a taxonomy has impeded data aggregation and consisting of three levels: domains, analysis of information about the classes, and outcomes. The effects of nursing practice. The use outcomes are organized into 31 of NOC allows nurses to determine classes and 7 domains (Moorhead, the outcomes of the care they Johnson, Maas, & Swanson, 2008). provide to individual patients. Each Each outcome consists of a outcome represents a concept used definition, a 5-point measurement to assess the state of a patient, scale or combination of scales, a list caregiver, family, or of associated indicators for the community/population prior to and outcome concept and supporting after interventions are performed. references. Every outcome, Patients are compared to a healthy associated indicators, and person of the same age and gender. measurement scale(s) are coded for Additionally, nurses caring for use in electronic healthcare records. patient populations can assess the NOC has been translated it to effectiveness of interventions Chinese, Dutch, French, German, provided to patient’s with similar Portuguese, Japanese, Korean, and conditions to better evaluate the Spanish. variances in clinical practice NOC can be implemented in resulting in an improved quality of critical pathways, plans of care and patient care. The ability to extract patient education records. The standardized nursing outcomes and adoption of NOC for use in an outcome within an electronic electronic health records provides health record provides the data an opportunity to conduct needed to clarify nursing effectiveness research using knowledge, advance nursing theory outcome data measured at different development, and determine the intervals. This effectiveness effectiveness of nursing care. The research can identify linkages research data provides information among the diagnoses; interventions on care quality for health care and outcomes for specific patient policy formulation. populations. NOC provides a mechanism to be compliant with Page 11 of 20

regulatory standards such as Joint Commission Standards.

Table 7: NOC example Outcome Scale Selected Indicators Pain Control Never Demonstrated Uses preventive measures Definition: Personal actions to (1) to Consistently Recognizes pain onset control pain. Demonstrated (5) Uses non-analgesic pain measures Uses analgesics appropriately Reports changes in pain symptoms to health care professional

The Omaha System

The Omaha System is a the components facilitate a problem research-based, standardized solving approach to care for taxonomy designed to enhance individuals, families, and practice, documentation, and communities. information management (The The Problem Classification Omaha System, n.d., 1). The Scheme is designed to organize Omaha System is a comprehensive, assessments and includes four yet simple, tool used by nurses and domains, forty-two problems, two other interdisciplinary healthcare sets of problem modifiers, and practitioners from the time of clusters of problem-specific signs admission through discharge. and symptoms. The Intervention Although it was initially developed Scheme is used to develop, plan, for home care, public health and and record actions taken for an other community settings, its use identified client problem. It consists has expanded internationally to of four categories, 75 unique nurse-managed centers, long-term targets, and client-specific care facilities, schools of nursing, as information. The Problem Rating well as hospital-based and other Scale for Outcomes is comprised of case management sites (Martin, three five-point Likert-type scales 2005). capturing client progress for the The Omaha System consists concepts of Knowledge, Behavior, of three components; a Problem and Status (Martin, 2005). Classification Scheme, Intervention The Omaha System Scheme, and Problem Rating Scale concepts are concise in meaning. for Outcomes. When used together, Each concept has a code that Page 12 of 20 facilitates linking the Omaha document the acute care discharge System to other terminology planning to the abstract categories systems and supports diverse nurse- in the Problem Classification sensitive outcome research studies. Scheme providing adequate The Omaha System is open source, coverage for concepts described which means the terms, definitions, within hospital records. This study and codes are not held under suggested the potential use of the copyright or licensed for sale so are Omaha System in the acute care available for use without setting, especially as a tool to permission. facilitate communication and The use of the Omaha continuity of care from hospital to System transforms data into home care. The potential to powerful information. Quantitative communicate the signs and data generated by the Omaha symptoms, problems, nursing System is increasingly valuable to interventions and the status of practice, education, and research. outcomes across settings is a Research studies have been valuable clinical and research tool conducted to evaluate if the Omaha (Bowles, 11). System provides terminology When the Omaha System is coverage needed to encode the used as the basis of electronic discharge transfer from acute care records, the Problem Classification to home care for elderly patients Scheme is the organizing with cardiac problems. One study framework for the assessment of investigated whether the Omaha individuals, families, and System enabled coding and communities; it is designed to linkages of patient signs and describe client-focused health symptoms, problems, and nursing related concerns, needs and interventions (Bowles, 2000, 1). strengths. The Intervention Scheme The use of the Omaha System was is the organizing framework to found to be effective in the transfer develop plans of care and clinical of care from the acute care to home pathways and to document care care because the Omaha System provided by the interdisciplinary consists of very clear and concise healthcare providers. The terminology in meaning and is Knowledge, Behavior, and Status understood by others on the subscales of the Problem Rating interdisciplinary team who are Scale for Outcomes operationalize frequently involved with the the measurement of client change transfer of care. The study also across points in time. reveled a linking between the majority of concepts needed to Page 13 of 20

Table 8: Omaha System example Problems Signs/Symptoms Categories Targets & Client- Ratings specific Information Page 14 of 20

Residence unsafe mats/ Teaching, safety Knowledge throw rugs Guidance and (remove/move =4 Counseling mats/throw rugs) Behavior=2 Status=3 Respiration abnormal breath sounds Surveillance signs/symptoms- Knowledge physical (vital signs, =2 bibasilar crackles, Behavior=2 changes) Status=2

Perioperative Nursing Data Set (PNDS)

The conceptual model of the documentation within a PNDS was derived from a principle computerized health record. The component factor analysis and a nurse-sensitive data elements of the theoretical discussion by an expert PNDS provide a universal language panel. The patient and their family for perioperative nursing practice are at the core of the PNDS and education that assists in the conceptual model and is the focus measurement and evaluation of for perioperative nursing care. The patient care outcomes. The PNDS PNDS is the only standardized consists of reproducible nursing data set that contains a interventions and a patient care single focus of perioperative outcome used to guide clinical nursing and addresses the research, facilities continuity of contributions of the professional care in the perioperative setting, nurse to the care of patients assists in the development of undergoing a surgical or invasive policies and procedures, and procedure. The data set is used for provides valid clinical data used for consistent clinical documentation, decision making and policy communication between clinicians formulation. in various practice settings, As a standardized nursing benchmarking activities, evaluating language, the PNDS is patient outcomes, orientation parsimonious, validated, reliable, programs and competency and useful for clinical practice. The evaluation and effectiveness PNDS terminology is clearly research. The PNDS addresses a set defined and consistent across time. of concepts that specifically Each PNDS concept contains a describe perioperative nursing machine-readable unique identifier diagnoses, nursing interventions, code. Once this code is assigned, and patient outcomes in surgical the unique identifier is retired and settings. the code never is reused. The PNDS provides a The PNDS data elements framework to standardize clinical consists of 74 nursing diagnoses, Page 15 of 20

133 nursing interventions, and 28 2007) and has collaborated with nurse-sensitive patient outcomes NANDA International to integrate arranged within patient care the nursing diagnoses coming from domains, e.g. safety, physiologic NANDA within PNDS. responses, and behavioral responses The PNDS model as a of the patient and family) whole illustrates the dynamic nature throughout the perioperative of the perioperative patient experience. After review of the experience and nursing presence. existing standardized nursing PNDS is organized by nurse- terminologies, the Association of sensitive patient outcomes that perioperative Registered Nurses provide measurable clinical Critical Issues Committee outcomes, nursing interventions concluded that NANDA was the statements, which are the only taxonomy that reflected many customary data elements that are of the phenomena of concern to documented with associated perioperative nurses [AORN], activity statements.

Table 9: Perioperative Nursing Data Set example Patient Outcome Criteria Nursing Interventions & Outcome Activities The patient The patient reports and . Assesses pain control demonstrates demonstrates pain controlled . Implements pain guidelines or reports based on recognized scale. . Evaluates responses to pain adequate pain Vital signs are within management interventions control expected ranges. throughout the perioperative period

Standardized Nursing Classification Knowledge Representation

Frequently, questions are The recommended relationships, asked regarding why an coming from the ANA recognized organization needs to implement terminology systems, between the the individual nursing terminology problem, intervention and outcomes systems when they have been lie within each of these systems. integrated within SNOMED CT. SNOMED CT only provides the SNOMED CT does not contain the concepts needed to develop this knowledge and explicit terminology knowledge representation within structure represented within the electronic health records. It is the standardized nursing terminologies. responsibility of those who build Page 16 of 20 the templates and forms within an complex collection of software and electronic health record to create database applications. It contains the recommended knowledge not only coded patient data but the representation and relationships to logic and supporting data structures be used at the point of care. required to present clinical users Standardized nursing terminologies data entry forms and to produce are critical to enhance the nursing reports in a form and in a language profession and are necessary to meaningful to the using clinician or support expanded approaches for manager. The use of SNOMED CT the representation of nursing combined with a set of nursing phenomena in response to languages parsed through a set of implementation challenges in terminology maps can provide both computer-based systems. There is a the consistency needed for need for robust information unambiguous data storage and structures concerning the way retrieval along with the richness nursing phenomena are represented required for meaningful nurse and managed, e.g. the relationship clinician interaction with the data. between nursing problems to In addition this architecture allows interventions to outcomes that is the coded data to be converted into critical for knowledge to be meaningful reports for secondary processed using a well-designed data uses (see Figure 1). computer algorithm. The EHR is a

Figure 1. The relationships between the EHR, the terminologies and the data repository. Page 17 of 20

Conclusion

There are many decisions The challenge for vendors and involved in developing and informatics nurses is to ensure the upgrading an electronic health consistent use of standardized record. Users are strongly terminologies within the electronic encouraged to evaluate research health record. The data aggregation findings on the terminologies of the standardized terminology currently in use and examine their provides nursing the ability to organizational business perform knowledge representation requirements before choosing a reliability and validity testing. This terminology system. The knowledge representation data development, application and extraction is used to support the evaluation of nursing terminology development of research specific to systems are priorities for the the nursing profession. Nurse- nursing profession. A critical first sensitive outcomes data, step in the selection of a vendor documented at the point of care, system is to ensure the vendor will demonstrate nurses do make a ontology and data storage can difference in patient care outcomes. support the integration of the ANA . recognized nursing terminologies.

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