Standardizing nursing data extracted from electronic health records for integration into a statewide clinical data research network.
Int J Med Inform
; 183: 105325, 2024 Mar.
Article
en En
| MEDLINE
| ID: mdl-38176094
ABSTRACT
BACKGROUND:
Care plans documented by nurses in electronic health records (EHR) are a rich source of data to generate knowledge and measure the impact of nursing care. Unfortunately, there is a lack of integration of these data in clinical data research networks (CDRN) data trusts, due in large part to nursing care being documented with local vocabulary, resulting in non-standardized data. The absence of high-quality nursing care plan data in data trusts limits the investigation of interdisciplinary care aimed at improving patient outcomes.OBJECTIVE:
To map local nursing care plan terms for patients' problems and goals in the EHR of one large health system to the standardized nursing terminologies (SNTs), NANDA International (NANDA-I), and Nursing Outcomes Classification (NOC).METHODS:
We extracted local problems and goals used by nurses to document care plans from two hospitals. After removing duplicates, the terms were independently mapped to NANDA-I and NOC by five mappers. Four nurses who regularly use the local vocabulary validated the mapping.RESULTS:
83% of local problem terms were mapped to NANDA-I labels and 93% of local goal terms were mapped to NOC labels. The nurses agreed with 95% of the mapping. Local terms not mapped to labels were mapped to the domains or classes of the respective terminologies.CONCLUSION:
Mapping local vocabularies used by nurses in EHRs to SNTs is a foundational step to making interoperable nursing data available for research and other secondary purposes in large data trusts. This study is the first phase of a larger project building, for the first time, a pipeline to standardize, harmonize, and integrate nursing care plan data from multiple Florida hospitals into the statewide CDRN OneFlorida+ Clinical Research Network data trust.Palabras clave
Texto completo:
1
Colección:
01-internacional
Base de datos:
MEDLINE
Asunto principal:
Registros Electrónicos de Salud
/
Terminología Normalizada de Enfermería
Tipo de estudio:
Guideline
Límite:
Humans
Idioma:
En
Revista:
Int J Med Inform
Asunto de la revista:
INFORMATICA MEDICA
Año:
2024
Tipo del documento:
Article
Pais de publicación:
Irlanda