Terms used by nurses to describe patient problems: can SNOMED III represent nursing concepts in the patient record?
OBJECTIVE
To analyze the terms used by nurses in a variety of data sources and to test the feasibility of using SNOMED III to represent nursing terms.


METHODS
Prospective research design with manual matching of terms to the SNOMED III vocabulary.


METHODS
The terms used by nurses to describe patient problems during 485 episodes of care for 201 patients hospitalized for Pneumocystis carinii pneumonia were identified. Problems from four data sources (nurse interview, intershift report, nursing care plan, and nurse progress note/flowsheet) were classified based on the substantive area of the problem and on the terminology used to describe the problem. A test subset of the 25 most frequently used terms from the two written data sources (nursing care plan and nurse progress note/flowsheet) were manually matched to SNOMED III terms to test the feasibility of using that existing vocabulary to represent nursing terms.


RESULTS
Nurses most frequently described patient problems as signs/symptoms in the verbal nurse interview and intershift report. In the written data sources, problems were recorded as North American Nursing Diagnosis Association (NANDA) terms and signs/symptoms with similar frequencies. Of the nursing terms in the test subset, 69% were represented using one or more SNOMED III terms.
Henry
S B
SB
University of California School of Nursing, San Francisco, USA.
Holzemer
W L
WL
Reilly
C A
CA
Campbell
K E
KE
D003695:Delivery of Health Care / Q000145:classification; D005069:Evaluation Studies as Topic; D006296:Health Services / Q000145:classification; D007407:Interviews as Topic; D009317:National Library of Medicine (U.S.); D009726:Nurses; D009729:Nursing / Q000145:classification; D009733:Nursing Diagnosis; D010347:Patient Care Planning; D011020:Pneumonia, Pneumocystis / Q000451:nursing; D012107:Research Design; D013358:Subject Headings; D009626:Terminology as Topic; D017432:Unified Medical Language System; D014481:United States