Description of COVID‐19 patients and mapping nursing data to ICNP 2021 reference set in SNOMED CT

Abstract

Aim To describe nursing care of COVID‐19 patients with International Classification for Nursing Practice (ICNP) 2019, ICNP 2021 reference set, and Systematized Nomenclature of Medicine–Clinical Terms (SNOMED CT). Background From the beginning of the COVID‐19 pandemic, nurses have realised the importance of documenting nursing care. Introduction It is important to recognise how real nursing data match the ICNP reference set in SNOMED CT as that is the terminology to be used in Iceland. Methods A descriptive study with two methods: (a) statistical analysis of demographic and coded clinical data identified and retrieved from Electronic Health Record (EHR) and (b) mapping of documented nursing diagnoses and interventions in EHRs into ICNP 2019, ICNP 2021 and SNOMED CT 2021. Results The sample consisted of all (n = 91) adult COVID‐19 patients admitted to the National University Hospital between 28 February and 30 June 2020. Nurses used 62 different diagnoses and 79 interventions to document nursing care. Diagnoses and interventions were best represented by SNOMED CT (85.4%; 100%), then by ICNP 2019 version (79.2%; 85%) and least by the ICNP 2021 reference set (70.8; 83.3%). Ten nursing diagnoses did not have a match in the ICNP 2021 reference set. Discussion Nurses need to keep up with the development of ICNP and submit to ICN new terms and concepts deemed necessary for nursing practice for inclusion in ICNP and SNOMED CT. Conclusion Not all concepts in ICNP 2019 for COVID‐19 patients were found to have equivalence in ICNP 2021. SNOMED CT–preferred terms cover the description of COVID‐19 patients better than the ICNP 2021 reference set in SNOMED CT. Implications for nursing and health policy Through the use of ICNP, nurses can articulate the unique contribution made by the profession and make visible the specific role of nursing worldwide.

Exploring Nursing Care for Patients With COVID-19 Using International Classification for Nursing Practice–Based Nursing Records

“…These findings were consistent with previous studies that have reported fever, cough, sputum, dyspnea, and myalgia as common symptoms of COVID-19, 29–31 and blood oxygen saturation and body temperature as the main clinical indicators for COVID-19 prognosis prediction 32 . Our findings were also consistent with those of the Icelandic study, 3 which especially analyzed nursing care for 91 patients with COVID-19 in the following aspects: diagnostic testing–related concepts such as laboratory result and arterial blood gas result appeared frequently in the ICU group, and respiratory status–related concepts such as sputum, cough, and dyspnea and infection concept appeared frequently in both the ICU and ward groups.…”

“…Although the ICNP offers precoordinated terms and concepts, it is not sufficient to describe specific problems and nursing interventions. 3 If nursing records are mapped to the systematized nomenclature of medicine clinical terms (SNOMED CT), the most widely used comprehensive terminology with fine granularity and an extensive hierarchy, it is anticipated that the terminology-based nursing records will reflect the phenomena or reality more precisely and in detail, enabling a more sophisticated analysis.…”

“…For example, “a patient has a cough” and “a patient does not cough” in diagnosis/outcome statements were mapped to “cough (10005249)” concept in focus axis with “presence (10046624)” and “none (10013253)” concepts in judgment axis, respectively. Although the ICNP offers precoordinated terms and concepts, it is not sufficient to describe specific problems and nursing interventions 3 . If nursing records are mapped to the systematized nomenclature of medicine clinical terms (SNOMED CT), the most widely used comprehensive terminology with fine granularity and an extensive hierarchy, it is anticipated that the terminology-based nursing records will reflect the phenomena or reality more precisely and in detail, enabling a more sophisticated analysis.…”

“…In 2020, a retrospective study of 1344 patients with COVID-19 identified nursing interventions and care provided to the patients using the Nursing Interventions Classification (NIC)–based records 2 . Thoroddsen et al 3 used nursing data to describe nursing care of COVID-19 patients during the first wave of the pandemic in Iceland. In addition, the impact of COVID-19 on nursing activities in intensive care units (ICUs) was analyzed using the Nursing Activities Score of inpatients from multiple centers in the Netherlands 1 .…”

Identification of Predictors for Clinical Deterioration in Patients With COVID-19 via Electronic Nursing Records: Retrospective Observational Study

“…Several studies have examined the content coverage of SNOMED CT in the nursing domain by mapping standardized nursing terminologies, such as the Nursing Intervention Classification, International Classification for Nursing Practice (ICNP), Clinical Care Classification System, North American Nursing Diagnosis Association-International, and Omaha system, into SNOMED CT [ 14 - 18 ]. Thoroddsen et al [ 19 ] described the nursing care of patients with COVID-19 using ICNP and SNOMED CT. SNOMED CT outperformed ICNP in representing COVID-19 diagnoses and interventions. In particular, SNOMED CT comprehensively covered nursing interventions for patients with COVID-19.…”