AMIA Annu Symp Proc - Standardized mapping of nursing assessments across 59 U.S. military treatment facilities.

Tópicos

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Resumo

JECTIVE: Create an interoperable set of nursing flowsheet assessment measures within military treatment facility electronic health records using the 3M Healthcare Data Dictionary (HDD).DESIGN: The project comprised three phases: 1) discovery included an in-depth analysis of the Essentris data to be mapped in the HDD; 2) mapping encompassed the creation of standard operating procedures, mapping heuristics, and the development of mapping tools; and 3) quality assurance incorporated validation of mappings using inter-rater agreement.RESULTS: Of 569,073 flowsheet concepts, 92% were mapped to the HDD. Of these, 31.5% represented LOINC concepts, 15% represented SNOMED CT and 1% represented both. 52.5% were mapped to HDD concepts with no standardized terminology representations.CONCLUSIONS: Nursing flowsheet data can be mapped to standard terminologies but there is not the breadth of coverage necessary to represent nursing assessments. Future work is necessary to develop a standard information model for the nursing process.

Resumo Limpo

jectiv creat interoper set nurs flowsheet assess measur within militari treatment facil electron health record use m healthcar data dictionari hdddesign project compris three phase discoveri includ indepth analysi essentri data map hdd map encompass creation standard oper procedur map heurist develop map tool qualiti assur incorpor valid map use interrat agreementresult flowsheet concept map hdd repres loinc concept repres snome ct repres map hdd concept standard terminolog representationsconclus nurs flowsheet data can map standard terminolog breadth coverag necessari repres nurs assess futur work necessari develop standard inform model nurs process

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