title: Informing standard development and understanding user needs with omaha system signs and symptoms text entries in community-based care settings.
abstract: The Omaha System is one of the most widely used standards for documentation in community-based settings. While researchers have focused upon this extensible classification scheme to understand and summarize structured data, few studies have analyzed the use of associated text. Two years of client records were accessed from two diverse sites utilizing the Omaha System 2005 revision: a skilled homecare, hospice, and palliative care program and a maternal child health home visiting program. Each problem allows users to enter text data for "other" signs and symptoms (S&S). Problems with the most frequent use of Other S&S were analyzed by a group of content experts to categorize associated text and inform future standard refinements. Text entries for Other S&S frequently contained duplicate entries, multiple concepts, medical diagnoses, interventions, or comments. A number of potential new and modified S&S were identified. Text entries for Other S&S appear valuable for informing future standard development.
authors.affiliation: Institute for Health Informatics.
authors.forename: Genevieve B
authors.initials: GB
authors.lastname: Melton
authors.forename: Bonnie L
authors.initials: BL
authors.lastname: Westra
authors.forename: Nandhini
authors.initials: N
authors.lastname: Raman
authors.forename: Karen A
authors.initials: KA
authors.lastname: Monsen
authors.forename: Madeleine J
authors.initials: MJ
authors.lastname: Kerr
authors.forename: Colleen H
authors.initials: CH
authors.lastname: Hart
authors.forename: Debra A
authors.initials: DA
authors.lastname: Solomon
authors.forename: Jill E
authors.initials: JE
authors.lastname: Timm
mesh_terms: D004282:Documentation; D006801:Humans; D018875:Vocabulary, Controlled