Chel Coenen | PubMed Health

PubMed2006

Developing an integrated electronic nursing record based on standards.

The Radboud University Nijmegen Medical Centre in the Netherlands develops a multidisciplinar (Electronic Health Record) based on the latest HL7 v3 (Health Level 7 version 3) D-MIM : Care provision. As part of this process we are trying to establish which nursing diagnoses and activities are minimally required. These NMDS (Nursing Minimal Data Set) are mapped or translated to ICF (for diagnoses) and CEN1828 Structures for (for activities). The mappings will be the foundation for the development of user interfaces for the registration of nursing activities. A homegrown custom-made web based configuration tool is used to exploit the possibilities of HL7 v3. This enables a sparkling launch of user interfaces that can contain the diversity of health care work processes. The first screens will be developed to support history taking for the nursing chart of the Neurology ward. The screens will contain both Dutch NMDS items and ward specific information. This will be configured dynamically per (group of) ward(s).

Medical Records Systems, Computerized↗

PubMed2002

Using ICIDH-2 in the classification of nursing diagnoses: results from two pilot studies.

BACKGROUND: Using ICIDH-2 in the classification of nursing diagnoses: results from two pilot studies Background. As an International Classification of Functioning and Disability, the ICIDH-2 is potentially relevant to the work of all health care professionals. Nurses, however, had little involvement in the development of this classification and have no tradition of using it. AIM: Two pilot studies were designed to explore the fit between ICIDH-2 and the nursing domain. METHODS: In the first study, experts (n=2) and nurses (n=9) were asked to identify and classify patient problems that they observed on a video taped case. In the second study, problem statements from nursing diagnoses (n=199) that had been retrieved from patient files were classified using ICIDH-2. Each problem statement was classified by a panel of three individuals. RESULTS AND CONCLUSION: Results from the two studies suggest that the ICIDH-2 is certainly relevant to the nursing discipline and allows a large majority of nursing diagnoses to be classified. It is recommended that nurses take an active role in the ongoing development of the ICIDH in order to further improve its usefulness to the nursing profession. LIMITATIONS: The studies were small-scale pilots performed in a single medical centre. Preliminary insight resulted from these pilots, but more research is needed.

Abstracting and Indexing↗