title: Toward the creation of an ontology for nursing document sections: mapping section names to the LOINC semantic model.
abstract: Clinical documents consist of groups of information (e.g., sections, panels, batteries). In order for clinical information to be shared, consistent formal naming principles for document components are desired. The purposes of this study were 1) to identify the components of existing electronic nursing documents, and 2) to represent them with Logical Observation Identifiers, Names, and Codes (LOINC) semantic model to examine the sufficiency of LOINC for non-ambiguously defining nursing document components as a prerequisite step toward the creation of an ontology for nursing document components. Section headings (n=308) were retrieved from the Eclipsys CIS; 38% were successfully represented with an inter-rater reliability of 0.73. Inconsistency exists in the names of the current section headings. In order for LOINC to better represent the document components, currently missing nursing section headings need to be added and extension of the attributes is desired.
authors.affiliation: School of Nursing and Department of Biomedical Informatics, Columbia University, New York, NY, USA.
authors.forename: Sookyung
authors.initials: S
authors.lastname: Hyun
authors.forename: Suzanne
authors.initials: S
authors.lastname: Bakken
mesh_terms: D004282:Documentation; D006801:Humans; D039703:Logical Observation Identifiers Names and Codes; D016347:Medical Records Systems, Computerized / Q000145:classification*; D009737:Nursing Records / Q000145:classification* / Q000592:standards; D012660:Semantics