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Representing Nursing Practice in EMR/EHRs.

Evelyn Hovenga^1,2

¹eHealth Education Pty Ltd, Melbourne, Australia.

Studies in Health Technology and Informatics

|July 25, 2024

Summary

This summary is machine-generated.

The ISO 18104 standard provides an updated nursing categorial structure for electronic health records (EHRs). This framework enhances the representation of nursing practice and demonstrates the value of nursing services in digital health ecosystems.

Keywords:

Categorial structure Clinical Models Nursing Data Semantic Interoperability Terminology

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Area of Science:

Nursing Informatics
Health Information Systems
Standardization in Healthcare

Background:

Electronic Medical Records (EMRs) and Electronic Health Records (EHRs) require standardized structures to represent complex nursing practice.
Existing systems may not adequately capture the nuances of nursing actions, diagnoses, and outcomes.
The need for a universally recognized nursing terminology is crucial for interoperability and data analysis.

Purpose of the Study:

To review and enhance the ISO 18104 technical standard for a nursing categorial structure.
To ensure optimal representation of nursing practice within EMR/EHRs and digital health ecosystems.
To align the standard with current information technologies and demonstrate the value of nursing services.

Main Methods:

Review of the ISO 18104 technical standard.
Application of ISO standard review guidelines.
Consultation with ISO member stakeholders.
Development of mindmaps to visualize the nursing practice knowledge domain.

Main Results:

A comprehensive nursing practice knowledge domain model presented as mindmaps.
Identification of patient groups using the 'type of subject of care' category.
Recognition of the collaborative role of nurses.
A structured information model encompassing nursing diagnosis, actions, and nurse-sensitive outcomes.

Conclusions:

The updated ISO 18104 categorial structure aligns well with modern information technologies.
Adoption of this standard facilitates the demonstration of the value of nursing services.
The framework supports conceptual and logical analysis of patient journeys and nursing practice.