Developing terminology for documenting perioperative nursing interventions.

Area of Science:

• Nursing Informatics
• Healthcare Terminology
• Clinical Documentation

Background:

• Standardized terminology is crucial for effective perioperative nursing documentation.
• The Perioperative Nursing Data Set (PNDS) requires further validation in diverse clinical settings.

Purpose of the Study:

• To develop and validate terminology for perioperative nursing interventions.
• To assess the coverage of existing PNDS interventions within a Finnish context.

Main Methods:

• Content analysis of 250 patient records, identifying 3442 terms and 104 nursing interventions.
• Delphi-panel evaluation (N=5) of term relevance (scale 1-4) and ISO reference terminology model compliance.
• Comparison of identified interventions with the original PNDS.

Main Results:

• 98 nursing interventions were accepted by the Delphi-panel with a high Content Validity Index (0.88-1.0).
• 80 interventions (60%) from the PNDS were covered by the study's findings.
• Identified interventions emphasized preventive care and patient coping strategies in the perioperative period.

Conclusions:

• Cross-cultural validation of nursing terminology is essential before widespread clinical adoption.
• The ISO reference terminology model provides a recommended framework for developing standardized nursing intervention concepts.