Developing hierarchical standardized home care nursing statements using nursing standard terminologies

https://doi.org/10.1016/j.ijmedinf.2020.104227Get rights and content

Highlights

  • Home care nursing records were highly mapped to nursing standard terminologies.

  • Nursing standards with different levels of granularity were aligned to form a hierarchical standardized statement structure.

  • The hierarchical structure can capture both abstract and detailed nursing documentation information.

Abstract

Objectives

Home care nursing requires high quality documentation to facilitate communication between health providers. Despite the awareness surrounding the importance of documentation, the home care nursing environment lends itself to incomplete and inaccurate documentation. Our study aims to develop a hierarchical standardized home care nursing statement (S-HCNS) structure that can increase documentation quality and completeness.

Methods

We collected a year of home care nursing notes from a hospital-based home care nursing agency in South Korea. Two nursing terminology standards, the International Classification for Nursing Practice (ICNP) and the Clinical Care Classification (CCC), were used to develop the hierarchical S-HCNS structure.

Results

A total of 1,230 S-HCNSs were derived by mapping 61,061 home care nursing notes to the ICNP. Among the total statements, 82.8 % were completely mapped and 0.3 % were not mapped. A total of 99.2 % of the S-HCNSs were classified within the CCC system to build a hierarchical S-HCNS structure.

Conclusions

The ICNP and CCC showed high mapping rates when building the hierarchical S-HCNSs. The unmapped concepts did not exist in the CCC or ICNP but existed in other terminology systems such as SNOMED CT. The differences in granularity between the two terminology standards enabled the development of a hierarchical structure, which enabled the representation of the appropriate level of detail found within clinical documentation. We expect this structure will increase documentation quality and completeness.

Introduction

Nursing records are a basic and essential source of data for various health care professionals to treat patients and develop care plans [1]. In some settings, such as home care nursing, nursing records are a critical communication tool as nurses are the clinicians that visit patients in-person most frequently [2,3]. These records, which contain nurses’ observations and assessments of patients, are used as evidence when developing a patient’s care plan with other health care providers.

Home care nursing is different from nursing services conducted in hospital settings. In the hospital, nurses provide continuous care from patient admission to discharge. Home care nurses provide intermittent care over an extended period of time, until the patient has recovered or is able to independently manage their chronic health condition, stay in the community, and avoid hospitalization. These special circumstances require high quality documentation to facilitate communication between healthcare providers [4]. Despite the awareness surrounding the importance of documentation, the home care nursing environment may lend itself to incomplete and inaccurate documentation [5]. This is especially true when nurses are not able to document in the patient’s home and must rely on their memory when they document at a later time.

One way to improve the quality of documentation is to use portable devices linked to home care nursing Electronic Health Record systems (EHRs) which can increase the accessibility of documentation and enable real-time documentation. Rather than focusing on improving environmental systems or devices, our study focused on existing home care documentation. Our study aims to develop a hierarchical standardized home care nursing statement (S-HCNS) structure that can achieve improvements in documentation accuracy, quality, and completeness when implemented in EHRs. Additionally, the hierarchical nature of this structure can represent nursing documentation information in both abstract and detailed ways and make it easy to visualize nursing activities.

Our study collected home care nursing documentation from a hospital-based home care nursing agency in South Korea for one year and used nursing terminology standards, the International Classification for Nursing Practice (ICNP) and the Clinical Care Classification (CCC), to develop the hierarchical S-HCNS structure. Previous studies have attempted to harmonize these two terminology systems [[6], [7], [8], [9], [10]]. The rationale for using these two nursing standards is that they have different levels of granularity and can be easily aligned to form a hierarchical standardized statement structure [11]. These standards afford the ability to represent both abstract and detailed information pulled from nursing documentation. The ICNP is an ontology-based reference terminology that consists of seven axes containing post-coordinated concepts and two pre-coordinated concepts (diagnosis concepts (DC) and intervention concepts (IC)) [12]. ICNP’s multi-axial structure and precise granularity enables easy mapping to nursing documentation written in natural language and grants the flexibility to express a range of patient conditions [13,14]. The CCC consists of 21 nursing care components that contain 60 major diagnoses and 77 major interventions at a highly abstract level [15]. The CCC care components, diagnosis, and intervention concepts provide a standard means for indexing nursing problems and nursing interventions. The applicability of both standards was confirmed in many areas of nursing practice [[16], [17], [18], [19], [20], [21], [22], [23]].

Section snippets

Data collection

The data used in this study was extracted from the nursing notes of 525 patients under hospital-based home care that were treated between January 1st and December 31st, 2013. The notes were written by home healthcare nurses affiliated with a home care nursing agency in Seoul, South Korea.

Ethics approval

This study was approved by the Institutional Review Board (MC13RASI0133) of Catholic University of Korea, Songeui Campus.

Data analysis

A total of 61,061 home care nursing notes were extracted from the EHR during the study

Demographics of home care nursing patients

A total of 61,061 home care nursing notes were reviewed. The demographics for patients included in the study were as follows: 37.5 % male, 62.5 % female, average age 58.9 years old, 20 % of patients older than 80 years, 7.2 % of patients younger than 30 years. The most common patient diagnoses were neoplasm (28.4 %), injury (19.1 %), and pregnancy, childbirth and the puerperium (17.0 %) (Table 1).

Development of standardized home care nursing statements (S-HCNS)

A total of 61,061 home care nursing notes were divided into 83,014 simple home care nursing

Discussion

A total of 1,230 (511 nursing diagnoses and 719 nursing interventions) hierarchical S-HCNSs were developed from 61,061 nursing notes by leveraging two nursing standard terminologies, the ICNP and the CCC. In general, we found a high mapping rate for both terminologies. As a result, we can hypothesize that the integration of the ICNP and the CCC are suitable for building a S-HCNS structure. Unmapped concepts were typically concepts that did not exist in either terminology system.

In the process

Conclusion

Leveraging two nursing standard terminologies is a useful tool for building a standardized home care nursing statement structure. The differences in granularity between the ICNP and CCC terminologies enabled the development of a hierarchical structure, which can help determine the level of detail in documentation needed by end users. Furthermore, abstract information can be statistically calculated and used for reporting and visualizing nursing work.

Author contributors

JL, MK initiated the study design. JL, MK worked on data collection and analysis. PD revised the initial study (doctoral thesis) design to be suitable for clinical practice. JL, JG led the writing of the manuscript, while all authors commented. All authors are accountable for the integrity of this work.

Summary Points

What was already known on the topic?

  • Special circumstances found in home care nursing require high quality documentation to facilitate communication between healthcare providers.

Declaration of Competing Interest

The authors have no conflicts of interest to disclose.

Acknowledgements

This study was developed based on author JL’s doctoral thesis. The authors would like to thank subject matter experts who participated in the validation of standardized home care nursing statements using the ICNP and the CCC.

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