ABSTRACT
A set of standard terms and codes for patient care data was derived from care planning and documentation materials submitted by 9 hospitals. The set contained 329 terms for Patient Problems, 308 terms for Patient Outcomes, and 1261 terms for Patient Care Actions. Six of the hospitals participated in a test of validity and reliability of the standard terms and codes. Manual audits were conducted on 465 patient records from two services in each hospital. All auditors achieved acceptable accuracy in coding. The auditors identified 18,995 items in the patient records as representing statements of Patient Problems, Patient Outcomes, or Patient Care Actions. The standard terms and codes matched 99.1% of these items. Thus, for the services audited, the standard terms and codes provided a valid representation of the Patient Problems, Patient Outcomes, and Patient Care Actions in the patient records.
