Clinical Knowledgebase Integration of Nursing Terminology

Area of Science:

• Health Informatics
• Nursing Informatics
• Clinical Knowledge Management

Background:

• Electronic Medical Records (EMRs) require robust clinical documentation and care planning tools.
• Nurses and allied health professionals need standardized terminology and processes for effective patient care.
• Existing systems may lack dynamic capabilities for generating comprehensive care plans.

Purpose of the Study:

• To describe the functionality of the Medicomp Point of Care Clinical Knowledgebase, MEDCIN®.
• To highlight MEDCIN®'s role in supporting integrated care documentation and planning.
• To demonstrate how MEDCIN® aligns with the American Nurses Association (ANA) nursing process.

Main Methods:

• Utilizing the MEDCIN® knowledgebase within EMRs.
• Employing clinical diagnoses, signs, and symptoms to prompt nursing terminology.
• Leveraging the MEDCIN® diagnostic index to dynamically construct Interactive Plans of Care (PoC).

Main Results:

• MEDCIN® prompts nursing terminology concepts based on patient data.
• Interactive Plans of Care (PoC) are dynamically generated using the six standards of the nursing process.
• Aggregated data analysis capabilities are enabled by the system.

Conclusions:

• MEDCIN® effectively supports integrated documentation and care planning for nurses and allied health professionals.
• The system facilitates adherence to the ANA nursing process through standardized terminology prompts.
• MEDCIN® is a widely adopted tool in US EMRs and global health information technology systems.