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The nursing history captures and records the patient's health status, so that a care plan evolves to meet the patient's individual needs. The nursing health history is a part of the initial assessment. A comprehensive history covers all health dimensions and plays a significant role in the assessment process. A comprehensive history includes the patient's biographical information, reasons for seeking health care, expectations, present and past health history, medications, and...
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Data collection gathers information needed to make accurate judgments about a patient's present condition. During a health history interview, subjective data is collected from the patient, their caregivers, or family members, and objective data is collected through observations and physical assessment. Patients are the primary source of subjective data. Thus information gathered from patients through interviews, observations, and physical examination is primary data. Secondary sources of...
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From capturing nursing knowledge to retrieval of data from a data warehouse.

Asta Thoroddsen1, Hanna K Guðjónsdóttir2, Elisabet Guðjónsdóttir2

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Summary

This project captured and stored nursing data using standardized terminologies in a data warehouse for improved retrieval and reuse. This enhances clinical decision-making by integrating nursing knowledge with hospital data.

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Area of Science:

  • Health Informatics
  • Nursing Informatics
  • Data Management

Background:

  • Nurses at LUH utilize standardized nursing terminologies for patient documentation in the Electronic Health Record (EHR).
  • Pre-defined nursing care order sets incorporating best practices and tacit knowledge have been developed and codified.
  • Existing patient-nursing data is stored in a dedicated data repository.

Purpose of the Study:

  • To capture and represent nursing data and knowledge for effective retrieval and reuse.
  • To integrate nursing data with clinical and financial hospital data in a data warehouse.
  • To enable the explicit use and dissemination of captured nursing knowledge.

Main Methods:

  • Standardized nursing terminologies were used to code tacit nursing knowledge.
  • Core nursing data elements were selected for transfer to a data warehouse.
  • Patient-nursing data was captured, stored, and linked with other warehouse data elements.

Main Results:

  • Nursing data is now captured and stored in a data warehouse alongside clinical and financial data.
  • Patient-nursing data can be related to other data elements within the warehouse.
  • The system facilitates the retrieval and reuse of nursing data and knowledge.

Conclusions:

  • The project successfully established a system for capturing, storing, and retrieving nursing data and knowledge.
  • Integrating nursing data into a data warehouse enhances its utility for clinical and research purposes.
  • This approach supports the explicit use and dissemination of nursing knowledge, improving patient care.