Application of the Omaha System in acute care

Although effective as a standardized language for documentation in communit y and public health settings, the Omaha System has not been evaluated in ac ute care settings. The purpose of this study was to evaluate the utility of the Omaha System to code the terms used by nurses when documenting hospita l care. The nursing documentation in 30 hospital records was content analyz ed for signs and symptoms, patient problems, and nursing interventions, the n coded into the categories of the Omaha System. Degree of match was evalua ted using concept match scores, and utility was determined using empirical, operational, and pragmatic criteria. Study findings suggest several streng ths (i.e., high reliability, coded 97% of the problems, easy to use) and so me limitations (lack of mutual exclusivity among terms, lack of semantic cl arity, the need for three new problems). This study has important implicati ons in demonstrating the utility of the Omaha System for possible expansion into acute care to standardize communication between the hospital setting and home care. (C) 2000 John Wiley & Sons, Inc.