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The first step toward data reuse: disambiguating concept representation of the locally developed ICU nursing
Hyeoneui Kim1, Marcelline R Harris, Guergana K Savova
1Decision Systems Group, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA. hkim@dsg.harvard.edu
Abstract:
Although an unambiguous and consistent representation is the foundation of data reuse, a locally developed documentation system such as nursing flowsheets often fails to meet the requirement. This article presents the domain modeling process of the ICU nursing flowsheet to clarify the meaning that its contents represent and the lessons learned during the activity. This study has been done as a first step toward reusing the data documented in a computerized nursing flowsheet for an algorithmic decision making. Following the ontology development processes proposed by other researchers, a conceptual model was developed using Protégé. Then, the existing information model was refined by fully specifying the embedded information structures and by establishing linkages to the conceptual model at the finest-grained concept level. Domain knowledge that the experienced nurses provided was critical to correctly interpret the meaning of the flowsheet contents as well as to verify the newly developed models. This study reassured the importance of the roles of a nurse informaticist to develop a computerized nursing documentation system that accurately represents the information needs in nursing practice.
Related Concept Videos
Flow Sheet
Here's a closer look at the examples of flowsheets commonly used by nurses:
Graphic Sheet Documentation:
Nursing Clinical Information System
A Nursing Clinical Information System (NCIS) is a specialized type of healthcare information system tailored to meet the unique needs of nursing practice. It incorporates the principles of nursing informatics to streamline information management and improve the quality of care delivery.
Critical attributes of NCIS include:
Formats for Nursing Documentation
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history, current medications, vital...
Methods of Documentation III: PIE
Methods of Documentation IV: Focus Charting
It typically involves three columns for recording information:
Fundamentals of Nursing Process I
