Terminology Mapping From Informatics and Nursing: Competencies and Applications Linda Q. Thede and...
-
Upload
caren-reynolds -
Category
Documents
-
view
231 -
download
1
Transcript of Terminology Mapping From Informatics and Nursing: Competencies and Applications Linda Q. Thede and...
![Page 1: Terminology Mapping From Informatics and Nursing: Competencies and Applications Linda Q. Thede and Jeanne Sewell.](https://reader035.fdocuments.net/reader035/viewer/2022081506/56649de55503460f94addc19/html5/thumbnails/1.jpg)
Terminology Mapping
From Informatics and Nursing: Competencies and Applications
Linda Q. Thede and Jeanne Sewell
![Page 2: Terminology Mapping From Informatics and Nursing: Competencies and Applications Linda Q. Thede and Jeanne Sewell.](https://reader035.fdocuments.net/reader035/viewer/2022081506/56649de55503460f94addc19/html5/thumbnails/2.jpg)
If data is to be interchangeable among healthcare systems it is necessary to use a nationally accepted standardized terminology. There are however many different nationally accepted standardized terminologies.
Theoretically, one can enter terms in one nationally recognized standardized terminology which can then be translated by the system to another nationally recognized terminology in a process known as “mapping.”
Mapping
![Page 3: Terminology Mapping From Informatics and Nursing: Competencies and Applications Linda Q. Thede and Jeanne Sewell.](https://reader035.fdocuments.net/reader035/viewer/2022081506/56649de55503460f94addc19/html5/thumbnails/3.jpg)
IllustrationIn this example, Nurse Stephanie in General Hospital is using the nationally accepted North American Nursing Diagnosis Association (NANDA-I) terms to enter nursing problems. Although she uses words to enter the terms, the system immediately translates the term to the appropriate code for NANDA-I.
General Hospital, however, stores data in its electronic healthcare record using the internationally accepted terminology SNOMED-CT.
To store the nursing problems charted by Stephanie it is necessary that the NANDA-I code be translated to the SNOMED-CT code. This is all done behind the scenes with no intervention from the user.This is accomplished using a mapping table that attempts to match the NANDA-I terms to concepts in SNOMED-CT.
![Page 4: Terminology Mapping From Informatics and Nursing: Competencies and Applications Linda Q. Thede and Jeanne Sewell.](https://reader035.fdocuments.net/reader035/viewer/2022081506/56649de55503460f94addc19/html5/thumbnails/4.jpg)
Stephanie Documents
Stephanie is preparing a transfer report for Mrs. Anders whose care will be the responsibility of the local Visiting Nurse Association. One of Mrs. Anders problems is acute pain, which she enters into the electronic healthcare record.
Acute Pain
![Page 5: Terminology Mapping From Informatics and Nursing: Competencies and Applications Linda Q. Thede and Jeanne Sewell.](https://reader035.fdocuments.net/reader035/viewer/2022081506/56649de55503460f94addc19/html5/thumbnails/5.jpg)
Systems Actions Behind Scenes (1)
Once Stephanie has entered the term “Acute Pain” the computer automatically translates that term to the code 00132 which is the code that NANDA-I uses to denote acute pain.
Acute Pain
becomes
00132
![Page 6: Terminology Mapping From Informatics and Nursing: Competencies and Applications Linda Q. Thede and Jeanne Sewell.](https://reader035.fdocuments.net/reader035/viewer/2022081506/56649de55503460f94addc19/html5/thumbnails/6.jpg)
Systems Actions Behind Scenes (2)
Because General Hospital stores data using SNOMED-CT the NANDA-I code (00132) is “mapped” to the SNOMED-CT code for the concept Acute Pain (274663001).
00132
Mapped to
274663001
![Page 7: Terminology Mapping From Informatics and Nursing: Competencies and Applications Linda Q. Thede and Jeanne Sewell.](https://reader035.fdocuments.net/reader035/viewer/2022081506/56649de55503460f94addc19/html5/thumbnails/7.jpg)
Systems Actions Behind Scenes (3)
The system now stores in Mrs. Anders chart the SNOMED_CT code 274663001 as a nursing problem.
274663001
![Page 8: Terminology Mapping From Informatics and Nursing: Competencies and Applications Linda Q. Thede and Jeanne Sewell.](https://reader035.fdocuments.net/reader035/viewer/2022081506/56649de55503460f94addc19/html5/thumbnails/8.jpg)
System Retrieval Actions (1)Mrs. Anders is discharged to the Visiting Nurse Association (VNA) where the nurses use the Omaha System to document. Nurse Valerie is assigned to Mrs. Anders. Before making her first visit she retrieves the transfer record. The nursing problem acute pain is retrieved by the system as its SNOMED_CT code 274663001.
274663001
![Page 9: Terminology Mapping From Informatics and Nursing: Competencies and Applications Linda Q. Thede and Jeanne Sewell.](https://reader035.fdocuments.net/reader035/viewer/2022081506/56649de55503460f94addc19/html5/thumbnails/9.jpg)
System Retrieval Actions (2)
The VNA system takes the SNOMED-CT code 274663001 for acute pain and using the mapping table translates the code to the Omaha System code for acute pain (24).
274663001
Mapped to
24
![Page 10: Terminology Mapping From Informatics and Nursing: Competencies and Applications Linda Q. Thede and Jeanne Sewell.](https://reader035.fdocuments.net/reader035/viewer/2022081506/56649de55503460f94addc19/html5/thumbnails/10.jpg)
System Retrieval Actions (3)
The software on Valerie’s computer translates the code 24 to the term that Valerie recognizes “Acute Pain”
24
becomes
Acute Pain
![Page 11: Terminology Mapping From Informatics and Nursing: Competencies and Applications Linda Q. Thede and Jeanne Sewell.](https://reader035.fdocuments.net/reader035/viewer/2022081506/56649de55503460f94addc19/html5/thumbnails/11.jpg)
System Retrieval Actions (3)
Acute Pain
Valerie sees the term “Acute pain” on her computer screen.
![Page 12: Terminology Mapping From Informatics and Nursing: Competencies and Applications Linda Q. Thede and Jeanne Sewell.](https://reader035.fdocuments.net/reader035/viewer/2022081506/56649de55503460f94addc19/html5/thumbnails/12.jpg)
Mapping Accuracy
Mapping for clear cut concepts such as acute pain is fairly accurate. However, the translation is not always this easy and mapping may create some loss or change of meaning.
![Page 13: Terminology Mapping From Informatics and Nursing: Competencies and Applications Linda Q. Thede and Jeanne Sewell.](https://reader035.fdocuments.net/reader035/viewer/2022081506/56649de55503460f94addc19/html5/thumbnails/13.jpg)
Review Storage
• Nurse enters NANDA Term• Without nurse effort:– System translates the term to the NANDA code for
that term– The NANDA code is mapped to the SNOMED-CT
code
• The system stores the SNOMED-CT code
![Page 14: Terminology Mapping From Informatics and Nursing: Competencies and Applications Linda Q. Thede and Jeanne Sewell.](https://reader035.fdocuments.net/reader035/viewer/2022081506/56649de55503460f94addc19/html5/thumbnails/14.jpg)
Review Retrieval
• Nurse asks to see the record for Mrs. Anders• The system then– Retrieves the SNOMED-CT code– Maps it to the Omaha System code– Translates it to the actual term from the Omaha
System.• Valerie reads the Omaha System.
![Page 15: Terminology Mapping From Informatics and Nursing: Competencies and Applications Linda Q. Thede and Jeanne Sewell.](https://reader035.fdocuments.net/reader035/viewer/2022081506/56649de55503460f94addc19/html5/thumbnails/15.jpg)
Review Concept
As far as Stephanie and Valerie are concerned they are communicating using the terminology with which they are familiar, while the system behind the scenes makes the necessary translations.