Development of the nursing problem list subset of SNOMED CT®.
OBJECTIVE
To create an interoperable set of nursing diagnoses for use in the patient problem list in the EHR to support interoperability.


METHODS
Queries for nursing diagnostic concepts were executed against the UMLS Metathesaurus to retrieve all nursing diagnoses across four nursing terminologies where the concept was also represented in SNOMED CT. A candidate data set was retrieved and included the nursing diagnoses and corresponding SNOMED CT concepts from the UMLS Metathesaurus. The team members identified the concepts that met the semantic selection criteria for inclusion in the nursing problem list.


RESULTS
1320 concepts were returned in the initial UMLS Metathesaurus query of nursing diagnostic concepts. Further analysis was conducted to identify those nursing diagnostic concepts mapped to SNOMED CT and duplicate concepts were removed resulting in 591 unique UMLS Metathesaurus concepts. The query extracted all concepts from two of the nursing terminologies that contained interventions and outcomes. After cleaning the dataset, the final count of SNOMED CT concepts in the nursing problem list subset is 369.


CONCLUSIONS
The problem list is a key component of the patient care and has been acknowledged as critical by the EHR Meaningful Use criteria. Nursing diagnoses on the problem list are foundational for constructing a nursing care plan. A multidisciplinary patient problem list will facilitate communication and evaluation of the contribution of nursing care to the patient's clinical care experiences and outcomes.
3M Health Information Systems Inc., 575 Murray Blvd., Murray, UT 84107, USA. samatney@mmm.com
Susan A
SA
Matney
Judith J
JJ
Warren
Jonathan L
JL
Evans
Tae Youn
TY
Kim
Amy
A
Coenen
Vivian A
VA
Auld
D059019:Clinical Coding / Q000379:methods; D057286:Electronic Health Records; D006801:Humans; D008490:Medical Informatics; D009732:Nursing Care / Q000592:standards*; D039061:Systematized Nomenclature of Medicine; D017432:Unified Medical Language System