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From Unstructured to Structured Nursing Documentation for Myocardial Infarction Patients Using Clinical Practice
Hyeyoung Lee1, Sumi Sung1, Jungeun Hong1
1College of Nursing, Research Institute of Nursing Science, Chungbuk National University, Cheongju, Republic of Korea.
Studies in Health Technology and Informatics
|May 23, 2026
Summary
This study analyzed nursing notes for myocardial infarction patients, mapping terms to SNOMED CT. The most common data captured involved observing patient condition and vital signs.
Area of Science:
- Clinical Informatics
- Nursing Informatics
- Medical Terminology
Background:
- Unstructured nursing documentation presents challenges in data extraction and analysis.
- Standardized terminologies are crucial for consistent interpretation of clinical data.
- Clinical practice guidelines (CPGs) provide a framework for patient care and documentation.
Purpose of the Study:
- To analyze unstructured nursing documentation for myocardial infarction (MI) patients.
- To map nursing documentation to SNOMED CT using domains derived from CPGs.
- To identify frequent concepts and data domains within MI nursing notes.
Main Methods:
- Utilized 72,234 records from 491 MI patients.
- Annotated records using 17 domains derived from the Canadian Cardiovascular Society (CCS) and American Heart Association/American College of Cardiology (AHA/ACC) CPGs.
- Mapped annotated data to SNOMED CT.
Main Results:
- The most frequent concept identified was "Taking patient vital signs (procedure)" (n = 4,432).
- The most frequent domain was "observation of patient condition" (n = 31,181, representing 43% of records).
- Demonstrated the feasibility of applying standardized terminologies to unstructured clinical notes.
Conclusions:
- Analysis of unstructured nursing documentation using SNOMED CT provides valuable insights.
- Observation of patient condition is a predominant aspect of nursing care for MI patients.
- Standardized mapping enhances the utility of nursing notes for research and quality improvement.
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