PubMed · 5174472
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Virginia Clare Sister. The problems facing OR nursing today.. https://doi.org/10.1016/s0001-2092(08)71310-3
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Everyday clinical nursing language is informal and idiosyncratic. Whether the everyday language of nurses can be represented by standardized vocabulary systems, such as the UMLS and SNOMED, was the focus of the study. Computer systems that allow clinicians to pick terms that are familiar are likely to be better accepted and thus more effective than systems that impose formal terminologies on users. Nursing phrases were extracted from handwritten shift notes, reduced to atomic-level terms, and matched to UMLS and SNOMED. Exact matches were obtained for 56% of terms in UMLS and 49% in SNOMED. Fifty-nine semantic types and 24 different source vocabularies were represented by the terms. Nursing vocabularies were represented by only 5% of source vocabulary citations.
The American Nurses Association Steering Committee on Databases to Support Nursing Practice has recognized three standardized nursing intervention classification systems. Because each of these classifications systems focuses on encoding informational abstractions of nursing actions, rather than providing a controlled vocabulary and compositional grammar from which informational concepts and abstractions can be constructed, the systems are necessary, but not sufficient, for representing what nurses do. In particular, computer based patient record systems focused on process understanding and process improvement will require atomic-level representations of nursing actions suitable for transformation into a variety of information abstractions, including, but not limited to, the abstractions contained in the three existing classification systems.