Development of a Provisional Domain Model for the Nursing Process for Use within the Health Level 7 Reference Information Model

Goossen, William; Ozbolt, Judy G.; Coenen, Amy; Park, Hyeoun-Ae; Mead, Charles N.; Ehnfors, Margareta; Marin, Heimar F.

doi:10.1197/jamia.m1085

Cited by 30 publications

(17 citation statements)

References 9 publications

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“…The nursing care plan is specific to care provided by the nurse; it is used by nursing students, faculty, and staff and includes nursing diagnoses (problems), expected outcomes, activities, and interventions. 7 The nursing care plan was first recommended in the 1930s. 6 Care plans started on paper but gradually became electronic.…”

Section: Nursing Process and The Care Planmentioning

confidence: 99%

“…Users in the United States can access SNOMED CT through the US National Library of Medicine's (NLM's) UMLS Metathesaurus. 7 The extensive, knowledge-based content of SNOMED CT provides the ability to accurately and consistently capture, retrieve, store, and share clinical data within a care plan. 21 The concepts in SNOMED CT are structured in a polyhierarchical model with 19 top-level categories.…”

Section: Systematized Nomenclature Of Medicine-clinical Termsmentioning

confidence: 99%

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Communicating Nursing Care Using the Health Level Seven Consolidated Clinical Document Architecture Release 2 Care Plan

Matney¹,

Buhl

Sheide³

2016

CIN: Computers, Informatics, Nursing

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A care plan provides a patient, family, or community picture and outlines the care to be provided. The Health Level Seven Consolidated Clinical Document Architecture (C-CDA) Release 2 Care Plan Document is used to structure care plan data when sharing the care plan between systems and/or settings. The American Nurses Association has recommended the use of two terminologies, Logical Observation Identifiers Names and Codes (LOINC) for assessments and outcomes and Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT) for problems, procedures (interventions), outcomes, and observation findings within the C-CDA. This article describes C-CDA, introduces LOINC and SNOMED CT, discusses how the C-CDA Care Plan aligns with the nursing process, and illustrates how nursing care data can be structured and encoded within a C-CDA Care Plan.

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Section: Nursing Process and The Care Planmentioning

confidence: 99%

Section: Systematized Nomenclature Of Medicine-clinical Termsmentioning

confidence: 99%

Communicating Nursing Care Using the Health Level Seven Consolidated Clinical Document Architecture Release 2 Care Plan

Matney¹,

Buhl

Sheide³

2016

CIN: Computers, Informatics, Nursing

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“…A D-MIM represents concepts from a particular clinical or administrative domain as classes, attributes, and roles in the HL7 RIM [8][9] so that the D-MIM functions as a bridge in the communication gap between health professionals. The HL7 RIM is a static model of health and health care information as viewed within the scope of HL7 standards development activities.…”

Section: Rim and Terminologymentioning

confidence: 99%

A Clinical Document Architecture (CDA) to Generate Clinical Documents within a Hospital Information System for E-Healthcare Services

Kim

Tran

Cho

2006

The Sixth IEEE International Conference on Computer and Information Technology (CIT'06)

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In general, hospital information systems are operated independently of each other. We propose a next-generation hospital information system (HIS) based on the HL7 clinical document architecture (CDA) including also an electronic health record (EHR) and a clinical data repository (CDR) to enable the sharing of medical information among health and medical institutions. We designed an XML schema through which an effective clinical document was generated from the HIS after defining the item regulations and the templates for the release form and radiation interpretation form. The schema was analyzed according to the HL7 reference information model, and HL7 V2.4 was used as the transmission protocol. In addition to proposing a new HIS, we attempted to define the CDA of a release form and create a generation, saving, and control system for the release form based on that definition, the first such undertaking in Korea.

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“…For example, nursing informatics researchers have made considerable progress in developing standardized terminologies to represent nursing assessments and nursing interventions in computer systems 3–6. Standardized terminologies and information structures enable computers to manipulate and integrate nursing information7 and may be useful for activities such as guiding data collection, integrating nursing research findings, and supporting documentation and analysis of nurses’ knowledge in practice.…”

Section: Capturing Nursing Knowledge In Computer Systemsmentioning

confidence: 99%

Nursing conceptualizations of research and practice

Peace

Lutz²

2009

Nursing Outlook

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Despite the fact that computer use in health care and nursing is burgeoning, nurses often find that they have inadequate tools with which to manage information about complex phenomena. Family is one such complex phenomenon of interest to nurses. Commonly used computer tools for managing information about families may not be congruent with the ways that individuals define their families and may not be consistent with nursing conceptualization of families as dynamic groups not necessarily limited to biologically related individuals. Building nursing knowledge on incongruent conceptualizations will result in inaccurate knowledge. Communication and collaboration between nurse researchers, clinicians, and nursing informatics researchers are needed in order to produce tools that are consistent with nursing conceptualization and that will support nursing research and practice. KeywordsFamily health; Assessment of patient/family; Information systems; Computers/technology; Family history; Knowledge representation; Nursing informaticsThe use of computers in health care and nursing is growing, as is the amount of information available and necessary for nursing research and practice. The increasing use of electronic health records (EHRs) and the proliferating availability of electronic health information indicate that the use of and reliance on computers in health care will continue to expand. Nursing has a valuable opportunity and an important responsibility to ensure that information is managed in computers in ways supportive of nursing research and practice.The purpose of this paper is to illustrate the pressing need for computational tools that are consistent with nursing conceptualization. By reviewing how nursing knowledge is captured in computers, exploring the complex concept of family, and comparing and contrasting the concept of family with computational tools commonly used within health care to manage information about families, we aim to depict the chasm between nursing conceptualization about family and the tools currently available to help nurses manage information about family in research and practice. We will critically examine how congruence or incongruence between the conceptualization and representation of complex concepts such as family can impact nurse researchers and clinicians. We will conclude by envisioning how computer tools based on nursing conceptualization might be developed, how they could benefit nurses and persons address for reprints: Jane Peace, PhD(c), H6/296 Clinical Sciences Center,

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Development of a Provisional Domain Model for the Nursing Process for Use within the Health Level 7 Reference Information Model

Cited by 30 publications

References 9 publications

Communicating Nursing Care Using the Health Level Seven Consolidated Clinical Document Architecture Release 2 Care Plan

Communicating Nursing Care Using the Health Level Seven Consolidated Clinical Document Architecture Release 2 Care Plan

A Clinical Document Architecture (CDA) to Generate Clinical Documents within a Hospital Information System for E-Healthcare Services

Nursing conceptualizations of research and practice

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