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Developing Standardized Physiologic Assessments.

Susan A Matney1, Theresa Tess Settergren2, Bonnie Westra3

  • 1Intermountain Healthcare.

Studies in Health Technology and Informatics
|June 23, 2016
PubMed
Summary
This summary is machine-generated.

A standardized nursing assessment terminology was created to improve data exchange and research. This new standard includes 106 observations and 348 values, coded in LOINC and SNOMED CT.

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Area of Science:

  • Nursing Informatics
  • Health Terminology Standards
  • Clinical Data Interoperability

Background:

  • Lack of a standardized nursing assessment terminology hinders information exchange and research.
  • Existing terminologies do not adequately represent the complexity of nursing assessments.
  • Need for a common language to facilitate consistent data collection and analysis in nursing.

Purpose of the Study:

  • To develop a standardized terminology for medical/surgical nursing assessments.
  • To code nursing assessment terms using established coding systems like LOINC and SNOMED CT.
  • To enhance the exchange of nursing information and support research.

Main Methods:

  • A team of nurse informaticists collaborated to create the standard.
  • Nursing assessment terms were systematically identified and defined.
  • Terms were coded using Logical Observation Identifiers Names and Codes (LOINC) and Systematized Nomenclature of Medicine - Clinical Terms (SNOMED CT).

Main Results:

  • The developed standard includes 106 nursing observations, with 50% being new LOINC codes.
  • It also incorporates 348 nursing values, with 20% being new SNOMED CT codes.
  • These terms are organized into fifteen panels, with 86% of panels utilizing new LOINC codes.

Conclusions:

  • The creation of a standardized nursing assessment terminology is a significant step towards improving data interoperability.
  • This new terminology facilitates more robust nursing research and clinical data exchange.
  • The use of LOINC and SNOMED CT ensures alignment with existing healthcare terminologies.