Table I. Future: electronic patient records individuals generating patient days. Research Alert. Journal of Professional Nursing. Nursing Minimum Data: abstraction tool for standardized, comparable, essential data.
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Am J Public Health, ;18 4 The registration of a nursing minimum data set in Belgium: six years of experience. Informatics in Healthcare - Australia. Journal of Nursing Management, 8, Using the nursing minimum data set for the Netherlands NMDSN to illustrate differences in patient populations and variations in nursing activities. Rapport Final Nursing Data Lausanne, ISE. Journal of Advanced Nursing.
Edmonton, Alberta, Canada: Author.
For a specified number of patients, every item on the data collection sheet will be completed. The study method is developed to be consistent with the ICN ethical guidelines for nursing research. In table 1, three NMDS systems are compared according to some of their characteristics to illustrate some issues that have to be dealt with.
Rules for mapping will be used and multiple raters can be used to increase reliability. Select feedback will be provided to the participating data collectors and project partners. These include frequency tables, fingerprints per service and country and an international map for all services, based on the Belgian methodology. In addition, the results of other explorative analysis will be reported. Vard I Norden. Simmons, D. Journal of Quality in Clinical Practice. International Journal of Nursing Practice. Computers in Nursing, 19 3 , A comparison on nursing minimum data sets.
Work in process. Annual review of nursing research, Journal of the American Medical Informatics Association, 5, 2, Geneva, Author. Int Nurs Rev. Ethical Guidelines for Nursing Research.
Geneva, ICN Headquarters. The national teams will be responsible for that. One other area of concern is that there is no funding available.
However, participants can apply in their own country for grants or funding, but it should be known that otherwise most of the work will be done on a voluntarily basis. The final preparations will take place in the beginning of , with a finalisation at NI By the end of the data collection for the pilot is foreseen and the results can be expected to be presented at Medinfo Those participating data collectors will receive a copy of the final study report.
The general and specific requirements for terminologies of different kinds are presented and a summary provided of current and future developments. The aims of the paper are to increase understanding of the need for standards and for collaboration in development, both within nursing and with other healthcare disciplines.
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Terminologies in Context First, a reminder of the underlying constructs and context that underpin all work on terminology in healthcare. The real world The Concept The Term Figure 1: Relationship between the term and what it represents Communication in health care takes many forms from the non-verbal through the everyday language of patients to the clinical languages used by different professions.
The other context to consider is the context of use of those terminologies that have been developed to represent healthcare concepts in electronic records and communications. These may be developed as part of the information system but where a terminology is provided from another source it needs to be incorporated into the system: i. This is important when considering the evaluation in use of terminologies as it is difficult to differentiate between problems with the terminology and problems with the information system in which the terminology is embedded.
Definitions A clinical terminology is a structured set of terms representing concepts relevant to clinical practice. The terminology may have additional features to support use in computer systems such as codes. Requirements There have been many statements about why nursing terminologies are needed but they all include the following general notions: 1. To be able to communicate, discuss, teach and nursing, using a common language to ensure shared understanding 2. To share and compare information about practice: monitoring quality and developing new knowledge through research 3.
To include nursing concepts in computer systems 4.
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To help ensure the visibility of nursing in health service data for planning, funding, policy etc. Within each of these general requirements, there are many specific requirements, depending on where you work, what you need to communicate and what kinds of questions you want to answer with your data. It is at the level of the specific requirement that the content and features of terminologies become important. An example of a specific re- 64 Casey, A. How is it measured in children? Does it include play preparation? Guided imagery? The terminology requirement here is for defined paediatric nursing diagnoses and interventions with validated measures or assessment criteria.
Having completed the research and developed practice in this area a dataset could be developed to monitor improvements in practice which might include: age of child, procedure, preparatory interventions, interventions during procedure, pain score and level of distress reported by child. An example of a specific requirement related to planning, funding and policy is the question: does the ratio of qualified to unqualified nurses make a difference to patient outcomes?
In a US study by Needleman et al outcomes were measured as incidence of adverse events such as diagnosis of pneumonia, urinary infection, DVT etc and were identified from discharge reports coded in ICD-9 International Classification of Diseases. There was an unmet need in the study for a classification with definitions of types of nurses. We would have difficulty doing such a study in Europe as we have no agreed listing of qualifications and types of nurses in our different countries. The US study would have been more useful for nursing policy if there had been data on broader outcomes than adverse events: a validated classification of patient outcomes was needed.
Item 3 on the list above of general requirements identifies a need to include nursing concepts in healthcare computer systems. However this is not a single requirement. It might be provided by the system vendor based on local developments at other sites where the same computer system is used. In contrast, if you are planning to implement facility-wide or even national multi-disciplinary records with electronic transfer of records and of data to national data repositories you need a comprehensive, multidisciplinary terminology, with interface and reference properties, mapped to classifications.
There are very few of these available, as the resources required to develop and maintain large-scale terminologies are significant. Of course you could try to link or map all the different terminologies together but in the NHS it has been decided that approach would cost more and be less likely to succeed than supporting a single large scale development. Journal of the American Medical Informatics Association.
New England Journal of Medicine. Ozbolt J. If the requirement is to quickly enter data into a computer record, a short alphabetically organised list of complete pre coordinated terms is useful. In contrast, a coded hierarchical classification is useful when the requirement is to undertake statistical analysis, for example, of the epidemiology of patient problems.
Many coun- 66 Casey, A. The next translation effort will be a German language version. Some countries have developed their own nursing terminologies and VIPS in Sweden is a well-established example. Others have developed specific term sets for specific purposes, for example, nursing interventions in the Belgian nursing minimum dataset.
The most important area of development currently is the evaluation, further development and maintenance of these existing resources. Terminologies that are widely used and meet the needs of those who use them need to be maintained and updated. But we do not have well developed evaluation methodologies and we need to publish more widely about the situations where particular terminologies have shown to have benefit.
The second area for development is to identify the gaps where existing terminologies need to be extended or new ones considered. There is a question here about who should lead this work and it is becoming clear that an international collaborative effort is needed to make best use of the scare expertise available in this field. An example of such collaboration is the Nursing Vocabulary Summit held at Vanderbilt University each year Ozbolt Terminology developers and experts from all parts of the world have been meeting to explore issues and to work on nursing elements of international health terminology standards.
The need for such standards is summarized by Hardiker et al : Differences between individual clinical terminologies prevent direct comparison and exchange of information. If there is to be comparability of data and interoperability among systems that communicate information, then there needs to be agreement on a standard way to represent nursing concepts in the various terminologies that are needed.
Largely thanks to the global collaborations facilitated by organisations like ACENDIO and the Nursing Vocabulary Summit, nursing is well represented on international standards bodies such as the concept representation working groups of the European and International Standards Organisations. Summary and Conclusions 1. Nursing and clinical terminologies are essential tools for nursing practice, education, research and management.
Many different nursing terminologies exist to reflect the many requirements and the diverse nature of nursing. Nursing language shares many common elements with other health care languages and with the everyday language of patients. Nursing must work collaboratively to identify gaps in terminology provision, develop standards and focus future developments to meet identified requirements. Im Mai wurde, nach umfassenden Vorarbeiten, mit einem neuen Produkt die gemeinsame Patientendokumentation realisiert.
Aus der langen Entwicklungsarbeit und Erfahrung ist ein Pflichtenheft entstanden, welches die Anforderungen an den Pflegeprozess genau beschreibt. In Kooperation mit dem Kantonsspital St. Gallen werden in 69 Lauterbach, A. Es ist ein langer Weg vom Einstieg in die elektronische Dokumentation bis zur Umsetzung der komplexen Anforderung aus Praxis und Theorie. In der Folge wurde dieses Projekt mit micom — Medicare realisiert und im Mai in Betrieb genommen.
Aktuelle Situation In der Klinik St. Im Lesezirkel werden Konzepte aus der Literatur S.