Development of the nursing problem list subset of SNOMED CT®

Matney, Susan; Warren, Judith J.; Evans, J.; Kim, Tae Youn; Coenen, Amy; Auld, Vivian A.

doi:10.1016/j.jbi.2011.12.003

Cited by 44 publications

(33 citation statements)

References 11 publications

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“…This study contributes perinatal specialty-specific problem elements, supporting the IHTSDO’s emphasis on using SNOMED CT for nursing problems and adding to the existing nursing problem list already present in SNOMED CT 20 . The interventions associated with P-FTR are also present in SNOMED CT.…”

Section: Discussionmentioning

confidence: 56%

“…Since this study was completed, additional examples of how standard terminologies can be used for nursing have been published and nursing informatics experts are working to increase nursing content and nursing value sets in standard terminologies 20, 21 22 . Therefore, it is important to discuss these study findings in the context of the current state of health IT and standard terminologies for nursing, with particular emphasis on LOINC and SNOMED CT.…”

Section: Discussionmentioning

confidence: 99%

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Mapping Perinatal Nursing Process Measurement Concepts to Standard Terminologies

Ivory

2016

CIN: Computers, Informatics, Nursing

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The use of standard terminologies is an essential component for employing 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 (ANA)-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, (n=21, 28%) in LOINC, (n=26, 34%) in ICNP, and (n=11, 15%) 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.

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Section: Discussionmentioning

confidence: 56%

Section: Discussionmentioning

confidence: 99%

Mapping Perinatal Nursing Process Measurement Concepts to Standard Terminologies

Ivory

2016

CIN: Computers, Informatics, Nursing

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“…Nursing diagnoses have been integrated into the "Clinical Findings" hierarchy, but it can be a challenge to locate the nursing diagnostic concepts in the extensive content in the "Clinical Findings" hierarchy. Therefore, the nursing working group of SNOMED CT assembled a nursing problem list subset of SNOMED CT. 24 This problem list can be used to encode the nursing diagnosis within the "Health Concerns Section." This subset is freely available on the NLM Web site.…”

Section: Encoding a C-cda Care Plan With Loinc And Snomed Ctmentioning

confidence: 99%

“…24 Goals are used in planning, to guide interventions, and provide benchmarks for evaluation. The "Goals" section of the C-CDA Care Plan is where the goal statements are represented.…”

Section: Interventions Section (Nursing Interventions)mentioning

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 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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“…They have been widely used for encoding clinical data for diagnoses, problem lists [1-3], billing [4], etc. The concepts linked by hierarchical and semantic relationships in controlled terminologies have also been facilitating major components of natural language processing systems, which lay a solid foundation for rule-based clinical decision support systems [5].…”

Section: Introductionmentioning

confidence: 99%

A comparative analysis of the density of the SNOMED CT conceptual content for semantic harmonization

Geller

Chen

2015

Artificial Intelligence in Medicine

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Objectives Medical terminologies vary in the amount of concept information (the “density”) represented, even in the same sub-domains. This causes problems in terminology mapping, semantic harmonization and terminology integration. Moreover, complex clinical scenarios need to be encoded by a medical terminology with comprehensive content. SNOMED Clinical Terms (SNOMED CT), a leading clinical terminology, was reported to lack concepts and synonyms, problems that cannot be fully alleviated by using post-coordination. Therefore, a scalable solution is needed to enrich the conceptual content of SNOMED CT. We are developing a structure-based, algorithmic method to identify potential concepts for enriching the conceptual content of SNOMED CT and to support semantic harmonization of SNOMED CT with selected other Unified Medical Language System (UMLS) terminologies. Methods We first identified a subset of English terminologies in the UMLS that have ‘PAR’ relationship labeled with ‘IS_A’ and over 10% overlap with one or more of the 19 hierarchies of SNOMED CT. We call these “reference terminologies” and we note that our use of this name is different from the standard use. Next, we defined a set of topological patterns across pairs of terminologies, with SNOMED CT being one terminology in each pair and the other being one of the reference terminologies. We then explored how often these topological patterns appear between SNOMED CT and each reference terminology, and how to interpret them. Results Four viable reference terminologies were identified. Large density differences between terminologies were found. Expected interpretations of these differences were indeed observed, as follows. A random sample of 299 instances of special topological patterns (“2:3 and 3:2 trapezoids”) showed that 39.1% and 59.5% of analyzed concepts in SNOMED CT and in a reference terminology, respectively, were deemed to be alternative classifications of the same conceptual content. In 30.5% and 17.6% of the cases, it was found that intermediate concepts could be imported into SNOMED CT or into the reference terminology, respectively, to enhance their conceptual content, if approved by a human curator. Other cases included synonymy and errors in one of the terminologies. Conclusion These results show that structure-based algorithmic methods can be used to identify potential concepts to enrich SNOMED CT and the four reference terminologies. The comparative analysis has the future potential of supporting terminology authoring by suggesting new content to improve content coverage and semantic harmonization between terminologies.

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Development of the nursing problem list subset of SNOMED CT®

Cited by 44 publications

References 11 publications

Mapping Perinatal Nursing Process Measurement Concepts to Standard Terminologies

Mapping Perinatal Nursing Process Measurement Concepts to Standard Terminologies

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

A comparative analysis of the density of the SNOMED CT conceptual content for semantic harmonization

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