TERMS USED BY NURSES TO DESCRIBE PATIENT PROBLEMS - CAN SNOMED-III REPRESENT NURSING CONCEPTS IN THE PATIENT RECORD

Objective: To analyze the terms used by nurses in a variety of data so urces and to test the feasibility of using SNOMED III to represent nur sing terms. Design: Prospective research design with manual matching o f terms to the SNOMED III vocabulary. Measurements: The terms used by nurses to describe patient problems during 485 episodes of care for 20 1 patients hospitalized for Pneumocystis carinii pneumonia were identi fied. Problems from four data sources (nurse interview, intershift rep ort, nursing care plan, and nurse progress note/flowsheet) were classi fied based on the substantive area of the problem and on the terminolo gy used to describe the problem. A test subset of the 25 most frequent ly used terms from the two written data sources (nursing care plan and nurse progress note/flowsheet) were manually matched to SNOMED III te rms to test the feasibility of using that existing vocabulary to repre sent nursing terms. Results: Nurses most frequently described patient problems as signs/symptoms in the verbal nurse interview and intershif t report. In the written data sources, problems were recorded as North American Nursing Diagnosis Association (NANDA) terms and signs/sympto ms with similar frequencies. Of the nursing terms in the test subset, 69% were represented using one or more SNOMED III terms.