Abstract
Disparate data must be represented in a common format to enable comparison across multiple institutions and facilitate Big Data science. Nursing assessments represent a rich source of information. However, a lack of agreement regarding essential concepts and standardized terminology prevent their use for Big Data science in the current state. The purpose of this study was to align a minimum set of physiological nursing assessment data elements with national standardized coding systems. Six institutions shared their 100 most common electronic health record nursing assessment data elements. From these, a set of distinct elements was mapped to nationally recognized Logical Observations Identifiers Names and Codes (LOINC®) and Systematized Nomenclature of Medicine–Clinical Terms (SNOMED CT®) standards. We identified 137 observation names (55% new to LOINC), and 348 observation values (20% new to SNOMED CT) organized into 16 panels (72% new LOINC). This reference set can support the exchange of nursing information, facilitate multi-site research, and provide a framework for nursing data analysis.
| Original language | English (US) |
|---|---|
| Pages (from-to) | 63-77 |
| Number of pages | 15 |
| Journal | Western journal of nursing research |
| Volume | 39 |
| Issue number | 1 |
| DOIs | |
| State | Published - Jan 1 2017 |
Keywords
- LOINC
- SNOMED CT
- data exchange standards
- medical surgical nursing
- multi-institutional research
- nursing assessment
- nursing informatics