title: Developing an integrated electronic nursing record based on standards.
abstract: The Radboud University Nijmegen Medical Centre in the Netherlands develops a multidisciplinar (Electronic Health Record) based on the latest HL7 v3 (Health Level 7 version 3) D-MIM : Care provision. As part of this process we are trying to establish which nursing diagnoses and activities are minimally required. These NMDS (Nursing Minimal Data Set) are mapped or translated to ICF (for diagnoses) and CEN1828 Structures for (for activities). The mappings will be the foundation for the development of user interfaces for the registration of nursing activities. A homegrown custom-made web based configuration tool is used to exploit the possibilities of HL7 v3. This enables a sparkling launch of user interfaces that can contain the diversity of health care work processes. The first screens will be developed to support history taking for the nursing chart of the Neurology ward. The screens will contain both Dutch NMDS items and ward specific information. This will be configured dynamically per (group of) ward(s).
authors.affiliation: EHR-project group Radboud University Nijmegen Medical Centre, the Netherlands. a.vangrunsven@ic.umcn.nl
authors.forename: Arno
authors.initials: A
authors.lastname: van Grunsven
authors.forename: Rianne
authors.initials: R
authors.lastname: Bindels
authors.forename: Chel
authors.initials: C
authors.lastname: Coenen
authors.forename: Ernst
authors.initials: E
authors.lastname: de Bel
mesh_terms: D016347:Medical Records Systems, Computerized / Q000458:organization & administration / Q000592:standards*; D009426:Netherlands; D009732:Nursing Care; D016730:Program Development; D014584:User-Computer Interface