Dutch Nurses' Association, PO Box 8212, 3503, Utrecht, RE, Netherlands.
Nursing Healthcare Innovation Technology Platform of the Dutch Nurses' Association, PO, Box 8212, 3503, Utrecht, RE, Netherlands.
BMC Med Inform Decis Mak. 2017 Dec 4;17(1):158. doi: 10.1186/s12911-017-0567-5.
Since the emergence of electronic health records, nursing information is increasingly being recorded and stored digitally. Several studies have shown that a wide range of nursing information is not interoperable and cannot be re-used in different health contexts. Difficulties arise when nurses share information with others involved in the delivery of nursing care. The aim of this study is to develop a nursing subset of patient problems that are prevalent in nursing practice, based on the SNOMED CT terminology to assist in the exchange and comparability of nursing information.
Explorative qualitative focus groups were used to collect data. Mixed focus groups were defined. Additionally, a nursing researcher and a nursing expert with knowledge of terminologies and a terminologist participated in each focus group. The participants, who work in a range of practical contexts, discussed and reviewed patient problems from various perspectives.
Sixty-seven participants divided over seven focus groups selected and defined 119 patient problems. Each patient problem could be documented and coded with a current status or an at-risk status. Sixty-six percent of the patient problems included are covered by the definitions established by the International Classification of Nursing Practice, the reference terminology for nursing practice. For the remainder, definitions from either an official national guideline or a classification were used. Each of the 119 patient problems has a unique SNOMED CT identifier.
To support the interoperability of nursing information, a national nursing subset of patient problems based on a terminology (SNOMED CT) has been developed. Using unambiguously defined patient problems is beneficial for clinical nursing practice, because nurses can then compare and exchange information from different settings. A key strength of this study is that nurses were extensively involved in the development process. Further research is required to link or associate nursing patient problems to concepts from a nursing classification with the same meaning.
自电子健康记录出现以来，护理信息越来越多地以数字方式记录和存储。多项研究表明，广泛的护理信息不可互操作，无法在不同的健康环境中重复使用。当护士与参与护理服务的其他人共享信息时，就会出现困难。本研究旨在基于 SNOMED CT 术语开发一套在护理实践中普遍存在的护理子集中的患者问题，以协助护理信息的交换和可比性。
采用探索性定性焦点小组收集数据。定义混合焦点小组。此外，护理研究人员和具有术语知识的护理专家以及术语学家参加了每个焦点小组。参与者来自各种实践背景，从不同角度讨论和审查患者问题。
7 个焦点小组共 67 名参与者选择并定义了 119 个患者问题。每个患者问题都可以用当前状态或风险状态进行记录和编码。包含的 119 个患者问题中，有 66%涵盖了国际护理实践分类所建立的定义，该分类是护理实践的参考术语。其余的则使用了官方国家指南或分类的定义。每个患者问题都有一个独特的 SNOMED CT 标识符。
为了支持护理信息的互操作性，基于术语（SNOMED CT）开发了一个国家护理子集中的患者问题。使用明确定义的患者问题有利于临床护理实践，因为护士可以比较和交换来自不同环境的信息。本研究的一个主要优势是护士广泛参与了开发过程。需要进一步的研究将护理患者问题与具有相同含义的护理分类概念联系或关联起来。
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