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Related Concept Videos

Flow Sheet01:17

Flow Sheet

2.5K
Flowsheets are valuable tools in nursing documentation. They enable healthcare professionals to efficiently record and monitor various patient assessments and measurements in a consolidated format.
Here's a closer look at the examples of flowsheets commonly used by nurses:
Graphic Sheet Documentation:
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Nursing Clinical Information System01:27

Nursing Clinical Information System

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Nursing Clinical Information System (NCIS)
A Nursing Clinical Information System (NCIS) is a specialized type of healthcare information system tailored to meet the unique needs of nursing practice. It incorporates the principles of nursing informatics to streamline information management and improve the quality of care delivery.
Critical attributes of NCIS include:
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Formats for Nursing Documentation01:28

Formats for Nursing Documentation

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Nursing documentation encompasses various formats designed to capture precise patient data, facilitate communication among healthcare team members, and ensure comprehensive and accurate patient records. Let's explore each of these formats in detail:
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history,...
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Documentation in Long-Term and Home Healthcare Setting01:29

Documentation in Long-Term and Home Healthcare Setting

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Documentation in long-term care facilities and home healthcare settings is crucial for ensuring continuous, coordinated, and comprehensive care for patients. Each setting has its specific documentation processes and tools:
Long-Term Care Facilities
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Documentation of Nursing Diagnosis01:10

Documentation of Nursing Diagnosis

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The nurse documents nursing diagnoses and enters them into the patient record. The identified patient's nursing diagnosis is either written out with a plan of care or entered into the electronic health record.
In some settings, data-driven computerized decision support systems are in place, allowing for more accurate nursing diagnoses. The database within one of these systems includes diagnostic labels defining characteristics, activities, and indicators for nursing. A nurse enters...
1.6K
Data Reporting and Recording01:24

Data Reporting and Recording

5.3K
Reporting and recording are crucial in data documentation. The timely, thorough, and accurate documentation of facts is essential when recording patient data. Failure to record findings during an assessment or interpretation of a problem will result in loss of information and make the patient document unreliable. The reader is left with general impressions if the information is not specific. A recording is documenting data of the individual's health information in a traceable, secure, and...
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Exploring common data model coverage of nursing flowsheet data: a pilot study using SNOMED CT and LOINC mapping.

Robin Austin1, Malin Britt Lalich1,2, Katy Stewart2

  • 1School of Nursing, University of Minnesota, Minneapolis, MN 55455, United States.

JAMIA Open
|December 16, 2025
PubMed
Summary
This summary is machine-generated.

Mapping nursing data to a national common data model (CDM) shows progress but highlights challenges. Significant gaps remain in integrating nursing flowsheet data into CDMs, limiting large-scale use for improved patient care and research.

Keywords:
common data modelelectronic health recordsevaluation studynursing informaticsnursing records

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Area of Science:

  • Health Informatics
  • Nursing Informatics
  • Data Standards

Background:

  • Nursing data, often documented in flowsheets, presents unique challenges for integration into standardized health data systems.
  • Common Data Models (CDMs) are crucial for data interoperability and large-scale health research, but their coverage of nursing-specific information requires evaluation.
  • Previous studies have highlighted the need for frameworks to assess the representation of diverse clinical data within CDMs.

Purpose of the Study:

  • To assess the content coverage of nursing data, specifically flowsheet information, within a publicly available Common Data Model (CDM).
  • To evaluate the extent to which nursing flowsheet concepts and values can be mapped to standardized terminologies like SNOMED CT and LOINC within the CDM.
  • To identify gaps and challenges in representing nursing data within a national CDM framework.

Main Methods:

  • A mapping study was conducted, following a 4-step process: identification of a CDM, definition of evaluation criteria, mapping of nursing flowsheet data, and application of evaluation criteria.
  • Nursing flowsheet concepts and values were mapped to target codes within Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT) and Logical Observation Identifiers Names and Codes (LOINC).
  • Mapping time per concept and per value was recorded to understand the effort involved in the process.

Main Results:

  • Over 65% of nursing flowsheet concepts and 56% of values were successfully mapped to SNOMED CT and LOINC target codes.
  • The average time to map a concept was significantly longer (1.19 minutes) than to map a value (0.64 minutes).
  • The study demonstrated progress in mapping nursing data but also revealed ongoing challenges in achieving comprehensive coverage.

Conclusions:

  • This mapping study reveals a significant gap in the integration of nursing data into national CDMs, impacting the ability to leverage this data at scale.
  • Further comprehensive mapping efforts are necessary to enhance the utility of nursing data within CDMs for research, policy, and clinical practice.
  • Addressing these gaps can improve real-time patient insights, support evidence-based nursing practices, and optimize nurse-sensitive patient outcomes.