Application of the Omaha System in acute care

Although effective as a standardized language for documentation in community and public health settings, the Omaha System has not been evaluated in acute care settings. The purpose of this study was to evaluate the utility of the Omaha System to code the terms used by nurses when documenting hospital care. The nursing documentation in 30 hospital records was content analyzed for signs and symptoms, patient problems, and nursing interventions, then coded into the categories of the Omaha System. Degree of match was evaluated using concept match scores, and utility was determined using empirical, operational, and pragmatic criteria. Study findings suggest several strengths (i.e., high reliability, coded 97% of the problems, easy to use) and some limitations (lack of mutual exclusivity among terms, lack of semantic clarity, the need for three new problems). This study has important implications in demonstrating the utility of the Omaha System for possible expansion into acute care to standardize communication between the hospital setting and home care.