RESUMO
OBJECTIVE: Create an interoperable set of nursing flowsheet assessment measures within military treatment facility electronic health records using the 3M Healthcare Data Dictionary (HDD). DESIGN: The project comprised three phases: 1) discovery included an in-depth analysis of the Essentris data to be mapped in the HDD; 2) mapping encompassed the creation of standard operating procedures, mapping heuristics, and the development of mapping tools; and 3) quality assurance incorporated validation of mappings using inter-rater agreement. RESULTS: Of 569,073 flowsheet concepts, 92% were mapped to the HDD. Of these, 31.5% represented LOINC concepts, 15% represented SNOMED CT and 1% represented both. 52.5% were mapped to HDD concepts with no standardized terminology representations. CONCLUSIONS: Nursing flowsheet data can be mapped to standard terminologies but there is not the breadth of coverage necessary to represent nursing assessments. Future work is necessary to develop a standard information model for the nursing process.
