Standardized mapping of nursing assessments across 59 U.S. military treatment facilities

Create an interoperable set of nursing flowsheet assessment measures within military treatment facility electronic health records using the 3M Healthcare Data Dictionary (HDD).

The project comprised three phases: 1) discovery included an in-depth analysis of the Essentris data to be mapped in the HDD; 2) mapping encompassed the creation of standard operating procedures, mapping heuristics, and the development of mapping tools; and 3) quality assurance incorporated validation of mappings using inter-rater agreement.

Of 569,073 flowsheet concepts, 92% were mapped to the HDD. Of these, 31.5% represented LOINC concepts, 15% represented SNOMED CT and 1% represented both. 52.5% were mapped to HDD concepts with no standardized terminology representations.

Nursing flowsheet data can be mapped to standard terminologies but there is not the breadth of coverage necessary to represent nursing assessments. Future work is necessary to develop a standard information model for the nursing process.