Mapping Perinatal Nursing Process Measurement Concepts to Standard Terminologies

The use of standard terminologies is an essential component for using data to inform practice and conduct research; perinatal nursing data standardization is needed. This study explored whether 76 distinct process elements important for perinatal nursing were present in four American Nurses Association–recognized standard terminologies. The 76 process elements were taken from a valid paper-based perinatal nursing process measurement tool. Using terminology-supported browsers, the elements were manually mapped to the selected terminologies by the researcher. A five-member expert panel validated 100% of the mapping findings. The majority of the process elements (n = 63, 83%) were present in SNOMED-CT, 28% (n = 21) in LOINC, 34% (n = 26) in ICNP, and 15% (n = 11) in CCC. SNOMED-CT and LOINC are terminologies currently recommended for use to facilitate interoperability in the capture of assessment and problem data in certified electronic medical records. Study results suggest that SNOMED-CT and LOINC contain perinatal nursing process elements and are useful standard terminologies to support perinatal nursing practice in electronic health records. Terminology mapping is the first step toward incorporating traditional paper-based tools into electronic systems.

[1]  Obstetric,et al.  Nursing care quality measurement. , 2014, Nursing for women's health.

[2]  Stanley M. Huff,et al.  Representing nursing assessments in clinical information systems using the logical observation identifiers, names, and codes database , 2003, J. Biomed. Informatics.

[3]  Yan Chen,et al.  The readiness of SNOMED problem list concepts for meaningful use of electronic health records , 2013, Artif. Intell. Medicine.

[4]  Catherine Ruhl,et al.  Interrater Reliability Testing of the Maternal Fetal Triage Index. , 2015, Journal of obstetric, gynecologic, and neonatal nursing : JOGNN.

[5]  K. Simpson.  Failure to Rescue: Implications for Evaluating Quality of Care During Labor and Birth , 2005, The Journal of perinatal & neonatal nursing.

[6]  Nicholas R. Hardiker,et al.  Semantic mappings and locality of nursing diagnostic concepts in UMLS , 2012, J. Biomed. Informatics.

[7]  A MatneySusan,et al.  Development of the nursing problem list subset of SNOMED CT , 2012 .

[8]  Margareta Ehnfors,et al.  Putting policy into practice: pre- and posttests of implementing standardized languages for nursing documentation. , 2007, Journal of clinical nursing.

[9]  Tae Youn Kim,et al.  Automating lexical cross-mapping of ICNP to SNOMED CT , 2016, Informatics for health & social care.

[10]  K. Dontje,et al.  Mapping Evidence-Based Guidelines to Standardized Nursing Terminologies , 2011, Computers, informatics, nursing : CIN.

[11]  Susan Matney,et al.  Development of the nursing problem list subset of SNOMED CT® , 2012, J. Biomed. Informatics.

[12]  Patricia C. Dykes,et al.  The adequacy of ICNP version 1.0 as a representational model for electronic nursing assessment documentation. , 2009, Journal of the American Medical Informatics Association : JAMIA.

[13]  Ankur Agrawal,et al.  Contrasting lexical similarity and formal definitions in SNOMED CT: Consistency and implications , 2014, J. Biomed. Informatics.

[14]  C. Spong,et al.  The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal monitoring: update on definitions, interpretation, and research guidelines. , 2008, Journal of obstetric, gynecologic, and neonatal nursing : JOGNN.

[15]  Dochterman,et al.  Nursing interventions classification (NIC). , 1992, Medinfo. MEDINFO.

[16]  Jungyun Hong.  Analyzing nursing notes by cross- mapping with ICNP® (International Classification for Nursing Practice) in a maternity unit of one of the tertiary hospitals in Pakistan , 2012, Nursing Informatics.

[17]  Patricia C. Dykes,et al.  A Framework for Harmonizing Terminologies to Support Representation of Nursing Practice in Electronic Records , 2012, Nursing Informatics.

[18]  Virginia K. Saba,et al.  Clinical Care Classification (CCC) System Manual: A Guide to Nursing Documentation , 2006 .

[19]  Ronald Cornet,et al.  Does SNOMED CT post-coordination scale? , 2014, MIE.

[20]  Bonnie L Westra,et al.  Achieving "Meaningful Use" of Electronic Health Records Through the Integration of the Nursing Management Minimum Data Set , 2010, The Journal of nursing administration.

[21]  B. Westra,et al.  Integrating the nursing management minimum data set into the logical observation identifier names and codes system. , 2008, AMIA ... Annual Symposium proceedings. AMIA Symposium.

[22]  M. Rutherford,et al.  Standardized Nursing Language: What Does It Mean for Nursing Practice? , 2008, OJIN: The Online Journal of Issues in Nursing.

[23]  Suzanne Bakken,et al.  Toward the Creation of an Ontology for Nursing Document Sections: Mapping Section Headings to the LOINC Semantic Model , 2006, AMIA.

[24]  Catherine H. Ivory.  Standardizing the words nurses use to document elements of perinatal failure to rescue. , 2014, Journal of obstetric, gynecologic, and neonatal nursing : JOGNN.

[25]  Rn Cenp Jane Englebright PhD,et al.  Defining and Incorporating Basic Nursing Care Actions Into the Electronic Health Record , 2013 .

[26]  Tiffany Harman,et al.  Standardized Mapping of Nursing Assessments across 59 U.S. Military Treatment Facilities , 2012, AMIA.

[27]  C. Cook.  Implementing the Modified Early Obstetric Warning Score (MEOWS) to Detect Early Signs of Clinical Deterioration and Decrease Maternal Mortality , 2014 .

[28]  Jeffrey P. Krischer,et al.  Comparing heterogeneous SNOMED CT coding of clinical research concepts by examining normalized expressions , 2008, J. Biomed. Informatics.

[29]  Deborah Kendall-Gallagher,et al.  Nurse specialty certification, inpatient mortality, and failure to rescue. , 2011, Journal of nursing scholarship : an official publication of Sigma Theta Tau International Honor Society of Nursing.

[30]  Nicholas R. Hardiker,et al.  Inter-terminology mapping of nursing problems , 2014, J. Biomed. Informatics.

[31]  Karen S. Martin,et al.  Selecting a standardized terminology for the electronic health record that reveals the impact of nursing on patient care , 2008 .

[32]  Jane Englebright,et al.  Defining and incorporating basic nursing care actions into the electronic health record. , 2014, Journal of nursing scholarship : an official publication of Sigma Theta Tau International Honor Society of Nursing.

[33]  L. Cavalini,et al.  Mapping a Nursing Terminology Subset to openEHR Archetypes. A Case Study of the International Classification for Nursing Practice. , 2015, Methods of information in medicine.

[34]  Sankey V. Williams,et al.  Hospital and Patient Characteristics Associated With Death After Surgery: A Study of Adverse Occurrence and Failure to Rescue , 1992, Medical care.

[35]  Suzanne Bakken,et al.  Using the LOINC Semantic Structure to Integrate Community-based Survey Items into a Concept-based Enterprise Data Dictionary to Support Comparative Effectiveness Research , 2012, Nursing Informatics.

[36]  Health information technology: initial set of standards, implementation specifications, and certification criteria for electronic health record technology. Final rule. , 2010, Federal register.

[37]  Catherine H. Ivory.  Standardizing failure to rescue elements in perinatal nursing documentation , 2011 .

[38]  Patricia C. Dykes,et al.  Harmonizing and extending standards from a domain-specific and bottom-up approach: an example from development through use in clinical applications , 2015, J. Am. Medical Informatics Assoc..

[39]  M. J. Beaulieu,et al.  Failure to Rescue as a Process Measure to Evaluate Fetal Safety During Labor , 2009, MCN. The American journal of maternal child nursing.