Representation of everyday clinical nursing language in UMLS and SNOMED

Everyday clinical nursing language is informal and idiosyncratic. Whether the everyday language of nurses can be represented by standardized vocabulary systems, such as the UMLS and SNOMED, was the focus of the study. Computer systems that allow clinicians to pick terms that are familiar are likely to be better accepted and thus more effective than systems that impose formal terminologies on users. Nursing phrases were extracted from handwritten shift notes, reduced to atomic-level terms, and matched to UMLS and SNOMED. Exact matches were obtained for 56% of terms in UMLS and 49% in SNOMED. Fifty-nine semantic types and 24 different source vocabularies were represented by the terms. Nursing vocabularies were represented by only 5% of source vocabulary citations.