Developing an integrated electronic nursing record based on standards

Area of Science:

• Health Informatics
• Nursing Informatics
• Clinical Informatics

Background:

• The Radboud University Nijmegen Medical Centre is developing a multidisciplinary Electronic Health Record (EHR).
• The EHR is based on Health Level 7 version 3 (HL7 v3) standards, specifically the D-MIM: Care provision model.
• Establishing a Nursing Minimal Data Set (NMDS) is crucial for efficient nursing documentation.

Purpose of the Study:

• To identify and define the minimally required nursing diagnoses and activities for the EHR.
• To map these NMDS components to the International Classification of Functioning, Disability and Health (ICF) for diagnoses and CEN 1828 Structures for activities.
• To lay the foundation for developing user-friendly interfaces for nursing activity registration.

Main Methods:

• Utilizing HL7 v3 standards for EHR development.
• Mapping nursing diagnoses to ICF and nursing activities to CEN 1828 Structures.
• Developing a custom web-based configuration tool to leverage HL7 v3 capabilities.
• Dynamically configuring user interfaces based on ward-specific information.

Main Results:

• The mappings serve as the basis for creating nursing activity registration interfaces.
• A custom configuration tool facilitates the dynamic generation of diverse healthcare work process interfaces.
• Initial development focuses on user interfaces for nursing chart history taking in the Neurology ward.
• These interfaces will integrate both Dutch NMDS items and ward-specific data.

Conclusions:

• The developed system enables a flexible and efficient EHR implementation.
• Dynamic configuration supports diverse healthcare workflows and ward-specific needs.
• This approach enhances the registration of nursing activities and improves data standardization.