between the concepts and terms.
4. Knowledge representation, as provided by electronic medical literature, guidelines, evi-dence-based practice protocols, and clinical decision support (Institute of Medicine, 2004, pp. 128-129).
Data Elements
Data elements are the most basic pieces of informa-tion collected, and in order to be able to use the col-lected data they must be defined clearly, discretely, and unambiguously. Definition includes determin-ing how the data are to be collected, by what soft-ware application, by what hardsoft-ware, and when they are to be collected. It is also important to establish how the data will be entered into the software sys-tem, e.g., as free text or by selection of predefined responses using coded values. Without clearly defined, consistently entered, unambiguous data, the ability to recover data with assurance of content is greatly diminished, as is the potential of the use of the data in future research.
The question of what data should be collected was answered in part through the development of minimum data sets, an example of which is the Nursing Minimum Data Set (NMDS) (Table 9-2).
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136 Understanding Organizations
TABLE 9-2 ANA-Approved Terminology Standards (February 24, 2006)
DATA SET PURPOSE
NMDS (Nursing Minimum Data Set)
NMMDS (Nursing Management Minimum Data Set)
TERMINOLOGIES
CCC (Clinical Care Classification)
ICNP (International Classifi-cation for Nursing Practice)
NANDA (North American Nursing Diagnosis Association)
NIC (Nursing Intervention Classification)
NOC (Nursing Outcome Classification)
The NMDS has 3 categories (nursing care, demographics, and service elements) with 16 data elements. This seminal work defined the minimum information that should be collected for every patient receiving nursing care and contributed to the foundation necessary for the development of nursing terminologies.
http://www.nursing.uiowa.edu/NI/collabs_files/Synopsis%20NMDS%20Nov%202003.pdf NMMDA was developed to meet the needs of nursing administrators. The NMMDS data set includes 17 data elements across the categories of nursing environment, nursing resources, and financial resources, and it is necessary to inform the strategic decisions of the nurse executive. (Huber D., Schumacher L., & Delaney C. [1997]. Nursing management minimum data set [NMMDS]. Journal of Nursing Administration, 27(4), 42–48.
PURPOSE
CCC emerged from a Medicare-funded nursing research study designed to assess and classify patients to determine the resources required to provide home health services.
CCC comprises two interrelated taxonomies:
■ 182 nursing diagnoses and outcomes, modified by an expected outcome or actual outcome axis, each of which is modified by three possible conditions: improved, stabilized, or deteriorated.
■ 198 nursing interventions modified by four types of action: assess/monitor, care/perform, teach/instruct, and manage/refer.
http://www.sabacare.com/
International Council of Nurses (ICN) is a federation of national nurse associations representing nursing in more than 128 member nations. ICNP is a derivative of the ICN, with the goal of articulating the contribution of nurses around the world to health care and promoting international standardization of nursing. ICNP includes nursing diagnoses, nursing interventions, and outcomes.
http://www.icn.ch/icnp.htm
NANDA provides nurses at all levels and in all areas of practice with a standardized nursing terminology with which to:
■ Name client responses to actual or potential health problems, life processes, and wellness
■ Document care for reimbursement of nursing services
■ Contribute to the development of informatics and information standards, ensuring the inclusion of nursing terminology in electronic health-care records
■ Facilitate study of the phenomena of concern to nurses for the purpose of improving patient care.
http://www.nanda.org/
NIC includes the full range of nursing interventions from general practice to specialty areas. Interventions include physiological and psychosocial, illness treatment and prevention, and health promotion for individuals, families, and communities as well as indirect care. Both independent and collaborative interventions are included.
http://www.nursing.uiowa.edu/centers/cncce/nic/index.htm
NOC labels and provides measures for comprehensive patient-focused outcomes that respond to nursing intervention. The outcomes are intermediate to the achievement of longer-range outcomes and employ a scale that provides quantifiable information. NIC facilitates the identification of risk adjustment factors for population groups.
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The NMDS identifies a limited set of data elements that should be collected for every patient. These ele-ments are clearly defined and serve as a foundation for further data collection. Fortunately, these data elements are generally collected by most electronic medical record systems.
Data elements are the most basic pieces of infor-mation to be collected, and each element must have a unique definition in order to ensure clear and con-sistent meaning. This process is not inconsequen-tial. For example, “blood pressure” is a term often assumed to be understood. The term, taken alone, can have various meanings relative to the context of
the user: a physical therapist may think of blood pressure in terms of pre- or postexercise; a neuron-science practitioner may think in terms of the posi-tion of the client at the time of measurement; the nurse clinician may evaluate blood pressure in the context of pre- or postprocedure. It becomes obvi-ous just how critical it is to have a clear, discrete, nonambiguous definition of each data element:
“Common data standards are essential to simplify and streamline data requirements and allow the information systems that carry the data to function as an integrated whole” (Institute of Medicine, 2004, p. 132).
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DATA SET PURPOSE
OMAHA System
PCDS (Patient Care Data Set)
PNDS (Perioperative Nursing Data Set)
MULTIDISCIPLINARY
TERMINOLOGIES PURPOSE
ABC (Alternative Billing Codes)
LOINC (Logical Observation Identifiers Names and Codes)
SNOMED-CT (Systemic Nomenclature of Medicine Clinical Terms)
This is a comprehensive practice and documentation tool for multidisciplinary health-care practitioners in any setting. The three components of the system are problem classification, intervention scheme, and problem rating for outcome.
http://www.omahasystem.org/
The PCDS was developed as a data dictionary of elements abstracted from clinical information systems. The PCDS is multiaxial and combinatorial (a system in which atomic terms are combined to create more complex concepts or problems or structures).
http://www.duke.edu/~goodw010/vocab/PCDS.html
Developed by the Association of Perioperative Registered Nurses, the PNDS is a standardized nursing vocabulary that addresses the perioperative patient experience from preadmission through discharge. It is the first, and to date the only, nursing language developed by a specialty organization that has been recognized by the ANA as a data set useful for perioperative nursing practice.
http://www.aorn.org/research/pnds.htm
ABC defines 5-character alphabetic symbols to represent thousands of integrative health-care products and services. The codes reflect the health-care delivered by acupuncturists, behavioral health-care workers, chiropractors, medical doctors, massage therapists, mental health–care practitioners, midwives, nurses, nutritionists, etc.
http://www.abccodes.com/ali/abc_codes/
The purpose of the LOINC database is to facilitate the exchange of laboratory and diagnostic results, generated by vendor systems, with other clinical information systems.
LOINC creates the translation so that other systems can understand and file the data.
LOINC data are used by practitioners for clinical care, outcomes management, and research.
http://www.regenstrief.org/loinc/
SNOMED-CT consists of health-care concepts, with unique meanings and formal logic-based definitions, that are organized into hierarchies. The number of terms and attributes presently enables approximately 1.5 million relationships to be defined in order to support a robust and discrete terminology system. SNOMED-CT can also be mapped to other medical terminologies and classification systems already in use.
http://www.snomed.org/
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Data can be appreciated best in the data-information-knowledge continuum. Data are fun-damental building blocks; they combine into a clear, objective definition of a specific fact, without attached meaning. Data are transformed into infor-mation when they are interpreted or analyzed and when a structure or organization has been applied.
Information becomes knowledge when it is incor-porated into the creation of thoughtful relationships and used to support decision processes meaning-fully (American Nurses Association, 2001). For example, assessment of pain at a specific moment in time provides data. The data gathered during that assessment gain meaning when placed in the context of previous pain assessments, and the pain data become information. Finally, when this pain assessment information is evaluated in the context of information regarding recent pain med-ication administration and other pain alleviation measures, the nurse develops knowledge regarding the effectiveness of the patient’s pain manage-ment plan.
Knowledge work uses transformed information in the context of specialized knowledge and expert-ise (Mayes, 2001). Registered nurses are knowl-edge workers by the very nature of the work they do and the continual synthesis of information and knowledge they weave throughout the decision processes inherent in patient care. Clinical judg-ment implies that nurses use their knowledge to interpret information in the context of the individ-ual patient and apply that knowledge to higher-level clinical plan development. The electronic medical record systems and knowledge representa-tion systems support and enhance the ready access of the clinical nurse to such data, information, and