Required Data for the Patient Record: Nursing and United Wellbeing.


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Required Data for the Patient Record: Nursing and Partnered Wellbeing Affirmation to the NCVHS Phrasing Hearings May 17-18, 1999 Judy G. Ozbolt, Ph.D., R.N., F.A.A.N., F.A.C.M.I., F.A.I.M.B.E. Teacher of Nursing and Biomedical Informatics, Vanderbilt College Outline
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Obliged Information for the Patient Record: Nursing and Allied Health Testimony to the NCVHS Terminology Hearings May 17-18, 1999

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Judy G. Ozbolt, Ph.D., R.N., F.A.A.N., F.A.C.M.I., F.A.I.M.B.E. Teacher of Nursing and Biomedical Informatics, Vanderbilt University

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Overview Definitions and prerequisites Issues for government activity Comparability of PMRI The Patient Care Data Set The Nursing Vocabulary Summit Conference, June 10-13, 1999

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What is PMRI? All information recorded amid consideration by suppliers of all orders Usually appraisal, analyses, orders, documentation of consideration Rarely objectives and clinical results (physiological, psychological, full of feeling, behavioral, utilitarian)

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Purpose of PMRI Reminder to suppliers Communication among suppliers Source of information for payers directors specialists

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Problems with PMRI Idiosyncratic recording by clinicians: information hard to recover translate total investigate Clinicians and others require diverse idea representations.

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Problems with PMRI (2) NO guidelines for nursing information NO retrievable information for administrations that expend 1/3 of working spending plan of healing centers Can’t study viability and expense adequacy of those administrations

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Status of Nursing Vocabularies 7 perceived by ANA need thoroughness, granularity, nuclear components, combinatorial syntax Diverse in reason, extension, shape, substance, and advancement No true standard No bound together dialect

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Benefits of standard nursing wording Building squares for arrangements and pathways: venture care necessities and staffing needs Decision support by means of hyperlinks Databases for quality, research Sensitive measures of value and adequacy to guide buying and regulations

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What can government do? Command provides details regarding quality, adequacy, and expenses in view of clinical nursing information. Oblige clinically approved phrasings at proper levels of granularity.

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What can government do? (2) Mandate wordings that meet developing criteria (ASTM). Bolster exploration and meetings to create and test wordings in nursing and united wellbeing.

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Comparability of PRMI Data presently NOT practically identical Comparable information discriminating to recognize best esteem administrations - best adjust of expense and results Comparable information important to repay, concentrate on, and enhance patient consideration administrations

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Patient Care Data Set Version 4.0, 1998 Codes and pre-facilitated terms for Problems (363 terms), Goals (311 terms), Orders (1357 terms) Outcomes characterized as Goal Evaluation Status Developed and tried at UVA, in a joint effort with UHC

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Patient Care Data Set Validated as far reaching of most terms utilized as a part of intense consideration Undergoing modification: Parsed into nuclear level components Combinatorial linguistic use Values of components (from practice) Links among qualities: clinical learning

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22 Care Components (got from HHCC) Activity Circulation Cognition Coping and Mental Health Fluids and Electrolytes Gastrointestinal Function Health Knowledge and Behaviors

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22 Care Components (2) Immunology Medications and Blood Products Metabolism Nutrition Physical Regulation Pre-, Intra-, Post-Procedure Respiration

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22 Care Components (3) Role Relationships Safety Self Care Self Concept Sensation, Pain, and Comfort Tissue Integrity Tissue Perfusion Urinary Elimination

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AXES Problems Goals Orders

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Elements on Problems Axis Subject Object Likelihood Status Degree Duration Value

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Elements on Problems Axis (2) Frequency Body Site Laterality

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Example Problem Statement Patient has affirmed, ceaseless, tolerably debilitated scope of movement (60% of ordinary) of left shoulder.

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Elements on Goals Axis Subject Object Performance Level of Performance Equipment Manifestations Goal Evaluation Status

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Example Goal Statement Patient will accomplish scope of movement inside adequate extent (80-90% of ordinary) by utilization of fitting hardware.

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Elements on Orders Axis Subject Object Action Indicators Method Risk Factors

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Example Order Set for “Activity Restrictions” Assess patient’s examples and levels of movement. Evaluate patient’s comprehension of action confinements and method of reasoning. Urge patient’s requesting that persons give help.

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Comparison of PCDS to HHCC and Omaha All got from patient records HHCC & Omaha: home care; PCDS: intense consideration PCDS utilizes segments adjusted from HHCC

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Comparison to NANDA and ICNP PCDS NANDA ICNP Subject Unit of Care Object Diagnostic Concept Focus of Care Status Modifier Judgment Likelihood Potentiality Likelihood Duration Acuity/Chronicity Chronicity Degree Degree Value Value Frequency Frequency Laterality Laterality Body Site Body Site

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Comparison to NIC PCDS Orders contrast in granularity with NIC Activities. NIC created by accord process; PCDS got from patient consideration reports

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Comparison to NOC gives legitimate and dependable measures of conditions or practices as results. PCDS characterizes results as Goal Evaluation Status; valuable for viability considers, predictable with HL7.

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How to make nursing vocabularies merge? Nursing Vocabulary Summit Conference, Vanderbilt, June 99 All vocabulary writers Language & measures specialists Federal offices Professional associations Health care organizations Health informatics industry

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Deliverables Recommendations for further improvement Guidelines/desiderata Papers for production Presentations

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Process Briefing book Learning about dialect & benchmarks Setting objectives Small gathering progress in the direction of objectives Reporting and spreading

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Financial Support National Library of Medicine Div. Of Nursing, HRSA AMIA Nursing Informatics WG American Medical Association 3M CareCentric Solutions Cerner Corporation

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Financial Support (2) IDX Kaiser Permanente Lexical Technology McKessonHBOC Oceania SMS SNOMED International

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Offer Will give formal report of the gathering to the board of trustees by end of summer

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Thank you. For additional data see Full content of confirmation Profile of PCDS Or contact Judy.Ozbolt@mcmail.vanderbilt.edu 615-936-1557 .:tslides

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