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

• Park HA
• Min YH
• Kim Y
• Lee MK
• Lee Y

• KMID: 2284551
• DOI: http://doi.org/10.4258/hir.2011.17.4.244

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

MeSH Terms

Concept Formation
Dietary Sucrose
Electronics
Electrons
Nursing Assessment
Nursing Process
Nursing Records
Semantics
Dietary Sucrose

Reference

1. Urquhart C, Currell R, Grant MJ, Hardiker NR. Nursing record systems: effects on nursing practice and healthcare outcomes. Cochrane Database Syst Rev. 2009. (1):CD002099.

2. Goossen W, Goossen-Baremans A, van der Zel M. Detailed clinical models: a review. Healthc Inform Res. 2010. 16:201–214.

3. Garde S, Knaup P, Hovenga E, Heard S. Towards semantic interoperability for electronic health records. Methods Inf Med. 2007. 46:332–343.

4. Elkin PL, Froehling D, Bauer BA, Wahner-Roedler D, Rosenbloom ST, Bailey K, Brown SH. Aequus communis sententia: defining levels of interoperability. Stud Health Technol Inform. 2007. 129(Pt 1):725–729.

5. Stroetmann V, Jung B, Rector A, Rodrigues J, Ustun B, Lewalle P, Dobrev A, Kalra D. Semantic interoperability deployment and research roadmap. 2007. Brussel, Belgium: The European Commission.

6. Park HA, Hardiker N. Clinical terminologies: a solution for semantic interoperability. J Korean Soc Med Inform. 2009. 15:1–11.

7. Beale T. Archetypes: constraint-based domain models for future-proof information systems. In : Workshop on Behavioural Semantics (Object Oriented Programming Systems Languages 2002); 2002 Nov 4-8; Washington, USA.

8. International Organization for Standardization (ISO). Health Informatics: quality criteria and methodology for detailed clinical models. International Organization for Standardization. ISO/CEN/Working Draft 13972. 2009. Geneva, Switzerland: ISO.

9. Hovenga E, Garde S, Heard S. Nursing constraint models for electronic health records: a vision for domain knowledge governance. Int J Med Inform. 2005. 74:886–898.

10. Garde S, Hovenga E, Buck J, Knaup P. Expressing clinical data sets with openEHR archetypes: a solid basis for ubiquitous computing. Int J Med Inform. 2007. 76:Suppl 3. S334–S341.

11. Coyle JF, Mori AR, Huff SM. Standards for detailed clinical models as the basis for medical data exchange and decision support. Int J Med Inform. 2003. 69:157–174.

12. Huff SM, Rocha RA, Coyle JF, Narus SP. Integrating detailed clinical models into application development tools. Stud Health Technol Inform. 2004. 107(Pt 2):1058–1062.

13. International Organization for Standardization (ISO). Health informatics: electronic health record communication - Part 3: Reference archetypes and term lists. ISO 13606-2. 2008. Geneva, Switzerland: ISO.

14. Goossen WT. Using detailed clinical models to bridge the gap between clinicians and HIT. Stud Health Technol Inform. 2008. 141:3–10.

15. Ahn SJ, Kim Y, Yun JH, Ryu SH, Cho KH, Kim SW, Kim SS, Kwak MS, Yu SJ, Koh YT, Choi DJ. Clinical contents model to ensure semantic interoperability of clinical information clinical contents model to ensure semantic interoperability of clinical information. J KIISE Softw Appl. 2010. 12:871–881.

16. Goossen WT. Intelligent semantic interoperability: integrating knowledge, terminology and information models to support stroke care. Stud Health Technol Inform. 2006. 122:435–439.

17. Min YH, Park HA. Development and validation of archetypes for nursing problems in breast cancer patients. J Korean Soc Med Inform. 2009. 15:393–401.

18. Kim Y, Park HA. Development and validation of detailed clinical models for nursing problems in perinatal care. Appl Clin Inform. 2011. 2:225–239.

19. Lee MK, Park HA. Development of data models for nursing assessment of cancer survivors using concept analysis. Healthc Inform Res. 2011. 17:38–50.

20. Kim YR, Park HA, Min YH, Lee MK, Lee YJ. Development of detatiled clinical models of nursing information for initial assessment. J Korean Clin Nurs Res. 2011. 17:101–112.

21. International Organization for Standardization (ISO). Conceptual framework for patient findings and problems in terminologies. ISO/TC215: 22789. 2010. Geneva, Switzerland: ISO.

22. International Organization for Standardization (ISO). Health informatics: integration of a reference terminology model for nursing. ISO/TC215: 18104. 2003. Geneva, Switzerland: ISO.

23. International Organization for Standardization (ISO). Health informatics: harmonized data types for information interchange. ISO/TC215: 21090. 2011. Geneva, Switzerland: ISO.

24. Kim HY, Cho IS, Lee JH, Kim JH, Kim Y. Concept representation of decision logic for hypertension management using SNOMED CT. J Korean Soc Med Inform. 2008. 14:395–403.

25. Polit DF, Beck CT. The content validity index: are you sure you know what's being reported? Critique and recommendations. Res Nurs Health. 2006. 29:489–497.

26. Clinical knowledge manager [Internet]. OpenEHR Foundation. 2007. cited at 2010 Aug 20. London, UK: OpenEHR Foundation;Available from: http://www.openehr.org/knowledge/.