The development of the nursing observation master file

Area of Science:

• Healthcare Informatics
• Nursing Practice
• Medical Terminology

Background:

• Patient status is expressed through nursing observations, doctor's symptom views, and examination results.
• Standardizing these terms is crucial for accurate clinical documentation and data analysis.

Purpose of the Study:

• To structure and standardize nursing observation item names and their corresponding result notations.
• To create a comprehensive dataset of patient status terms for improved clinical data management.

Main Methods:

• A bottom-up approach was used to collect terms directly from clinical practice.
• An 8-step method was applied for structuring and standardizing observation item names and result notations.
• A master list was created to ensure a one-to-one transcription of observation results to item names.

Main Results:

• A total of 1,653 unique sets of observation item names and result notations were collected and standardized.
• The standardization process ensured distinct entries for different result notations associated with the same observation item.

Conclusions:

• The developed standardized terminology facilitates consistent and accurate recording of patient status.
• This structured dataset enhances the utility of clinical data for research, quality improvement, and electronic health records.