Description of COVID-19 patients and mapping nursing data to ICNP 2021 reference set in SNOMED CT.

ABSTRACT

AIM: To describe nursing care of COVID-19 patients with International Classification for Nursing Practice (ICNP) 2019, ICNP 2021 reference set, and Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT). BACKGROUND: From the beginning of the COVID-19 pandemic, nurses have realised the importance of documenting nursing care. INTRODUCTION: It is important to recognise how real nursing data match the ICNP reference set in SNOMED CT as that is the terminology to be used in Iceland. METHODS: A descriptive study with two methods: (a) statistical analysis of demographic and coded clinical data identified and retrieved from Electronic Health Record (EHR) and (b) mapping of documented nursing diagnoses and interventions in EHRs into ICNP 2019, ICNP 2021 and SNOMED CT 2021. RESULTS: The sample consisted of all (n = 91) adult COVID-19 patients admitted to the National University Hospital between 28 February and 30 June 2020. Nurses used 62 different diagnoses and 79 interventions to document nursing care. Diagnoses and interventions were best represented by SNOMED CT (85.4%; 100%), then by ICNP 2019 version (79.2%; 85%) and least by the ICNP 2021 reference set (70.8; 83.3%). Ten nursing diagnoses did not have a match in the ICNP 2021 reference set. DISCUSSION: Nurses need to keep up with the development of ICNP and submit to ICN new terms and concepts deemed necessary for nursing practice for inclusion in ICNP and SNOMED CT. CONCLUSION: Not all concepts in ICNP 2019 for COVID-19 patients were found to have equivalence in ICNP 2021. SNOMED CT-preferred terms cover the description of COVID-19 patients better than the ICNP 2021 reference set in SNOMED CT. IMPLICATIONS FOR NURSING AND HEALTH POLICY Through the use of ICNP, nurses can articulate the unique contribution made by the profession and make visible the specific role of nursing worldwide.