Objectives: 1) Spotlight the value of the US Core Data for Interoperability (USCDI) to analyze nurses’ work. 2) Identify nursing decision support that includes interoperable core data. 3) Discuss teaching strategies to move nurses from narrative to structured documentation.
Purpose: Computers are no match for humans in understanding words. Narrative nursing notes in electronic health records (EHR) are quite limited in allowing data sharing about nursing problems and interventions. Standardized terminology in EHRs will facilitate data sharing for nursing quality improvement, and decision support. “Collect data once, use many times.”
The US Core Data for Interoperability (USCDI) identifies core data for nursing documentation with standardized, coded terminologies including: SNOMED CT, Systematized Nomenclature of Medicine Clinical Terms—used to capture clinical problems, interventions, and goals; LOINC, Logical Observation Identifiers Names and Codes—used to identify health measurements, observations, and documents; and RxNorm—used to identify medications. In addition, core data is useful for computerized problem-solving used in quality improvement and decision support to analyze large volumes of data from monitors and electronic health records.
Description: The goal for sharing nursing documentation is to teach students and practicing nurses how to replace narrative notes with interoperable standardized terminology. Terminologies approved by the American Nurses Association, mapped to SNOMED-CT, have familiar terms for nursing problems, interventions, and goals. For example, the clinical care classification (CCC) nursing terminology is currently used within the Hospital Corporation of America (HCA), Vanderbilt, and other health systems, for computer-readable nursing documentation to build reports that support patient safety and ANCC Magnet recognition. Documentation is streamlined and fit into nursing workflows.
Evaluation and implications for nursing: To practice documentation, Rutgers graduate students added structured terms to narrative SOAP (subjective-objective-assessment-plan) notes. CCC nursing diagnoses and expected outcomes were added to medical billing diagnoses in the Assessment. CCC nursing interventions were added to medical billing orders in the plan. For example, assessment with medical diagnosis ICD10 Z30.9 encounter for general counseling and advice on contraception would also include CCC K.25.5.1 infection risk, expected to improve.
Plan, with medical billing for intermediate encounter would include an order set for contraceptive prescription as well as CCC H 24.4.3 teach medication treatment, K 30.3.3 teach infection control, and CCC H24.4.2, manage medication treatment with return for BP check and refill in 6 months. With CCC documentation, nurses’ contribution to patient medication-taking and avoiding sexually transmitted disease will be visible. Quality metrics may be calculated. After the documentation assignment, the students that were surveyed agreed that structured data on nursing interventions is important for performance measurement and to uncover nursing’s contributions to patient outcomes.