Healthc Inform Res.  2011 Dec;17(4):244-252. 10.4258/hir.2011.17.4.244.

Development of Detailed Clinical Models for Nursing Assessments and Nursing Interventions

Affiliations
  • 1College of Nursing, Seoul National University, Seoul, Korea. yulha74@snu.ac.kr
  • 2School of Nursing, Columbia University, New York, USA.

Abstract


OBJECTIVES
The aim of this study was to develop and validate Detailed Clinical Models (DCMs) for nursing assessments and interventions.
METHODS
First, we identified the nursing assessment and nursing intervention entities. Second, we identified the attributes and the attribute values in order to describe the entities in more detail. The data type and optionality of the attributes were then defined. Third, the entities, attributes and value sets in the DCMs were mapped to the International Classification for Nursing Practice Version 2 concepts. Finally, the DCMs were validated by domain experts and applied to case reports.
RESULTS
In total 481 DCMs, 429 DCMs for nursing assessments and 52 DCMs for nursing interventions, were developed and validated. The DCMs developed in this study were found to be sufficiently comprehensive in representing the clinical concepts of nursing assessments and interventions.
CONCLUSIONS
The DCMs developed in this study can be used in electronic nursing records. These DCMs can be used to ensure the semantic interoperability of the nursing information documented in electronic nursing records.

Keyword

Semantics; Concept Formation; Terminology; Nursing Process; Documentation
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