title: Representation of nursing terms for the description of patient problems using SNOMED III.
abstract: We conducted an experiment to determine if the terms recorded by nurses in the patient chart to describe patient problems could be represented using SNOMED III terms. The data sources for the patient problems were the nurses' progress notes and nursing care plans from 485 patient encounters in three diverse settings (NR02215). We entered the nursing terms into a relational database. We loaded the SNOMED III terms into a relational database and created a word index. We determined matches by identifying the English description of the SNOMED III term that best matched the term charted by the nurses. Sixty-nine percent of the nursing terms in the test subset were matched using one or more SNOMED III terms. We identified redundant SNOMED III terms for several nursing terms including fear and diarrhea. Our results suggest that terms recorded by nurses in the patient chart can be represented using SNOMED III terms. Further enhancement and refinement will improve the domain completeness of SNOMED III as a controlled healthcare vocabulary and decrease redundancies.
authors.affiliation: Department of Mental Health, Community, and Administrative Nursing, University of California, San Francisco.
authors.forename: S B
authors.initials: SB
authors.lastname: Henry
authors.forename: K E
authors.initials: KE
authors.lastname: Campbell
authors.forename: W L
authors.initials: WL
authors.lastname: Holzemer
mesh_terms: D006801:Humans; D009729:Nursing; D009737:Nursing Records / Q000145:classification*; D010347:Patient Care Planning; D013358:Subject Headings; D009626:Terminology as Topic