4th Annual NDNQI Data Use Conference Catherine Kleiner, PhD, RN Carol Petersen RN, BSN, MAOM, CNOR
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1 4th Annual NDNQI Data Use Conference Catherine Kleiner, PhD, RN Carol Petersen RN, BSN, MAOM, CNOR Describe mapping standardized nursing language to traditional record labels and values in an EHR. Identify how standardized data elements can facilitate research, quality initiatives and reporting. 1
2 Where is the valid, reliable, interpretable, and reusable data from the patient record? Is the clinical record a data mine or a data cemetery? (Ozbolt, 2000) Standardized data allows nurse scientists to compare interventions effectiveness on patient outcomes. Definition Clinically useful data set that describes nursing practice Controlled vocabulary» Single concept» Concept is the embodiment of a particular meaning» Has only one coherent meaning» Concept Permanence» Unique identifier» Formal definitions 2
3 Need for perioperative standard method of documentation Need for data to measure clinical impact versus fast turnovers Need to document the value, cost-effectiveness, and contributions of professional nurses Need for reliable perioperative data for research Provides reliable homogeneous data Supports benchmarking activities across settings & institutions Comparison of clinical data from large number of patients/facilities Provides valid clinical data for decision making & policy formulation Provides standardized language & definitions to develop databases to support the evaluation of resource utilization Assists in the examination of the relationship of cost to quality & effectiveness 3
4 Provides clarity, preciseness, and consistency Makes perioperative practice visible Reflects clinical workflow Need for reliable and valid perioperative data Enables data capture to compare effectiveness Integrated into the electronic health record (EHR) 1999 PNDS recognized as a terminology that describes perioperative nursing practice Criteria: Supports one or more components of the nursing process Unique contribution to nursing practice Clinically relevant Tested for reliability and validity Supports one or more of the nursing domains Unique identifiers 4
5 National Library of Medicine American Society for Testing & Materials American National Standards Institute HL 7 Federal agencies National Committee on Vital & Health Statistics Health Care Financing Administration National Center for Health Statistics Mapped in SNOMED Consists of data elements that are: Clearly defined Common to all procedures Consistent across time Related to the delivery of care Appropriate for use in any surgical setting 5
6 Outcomes reflect observable, measurable, physiological, and psychological responses to perioperative nursing interventions Unique identifier Definition Concise clinical judgment label of a perioperative patient problem formulated for the purpose of directing nursing actions intended to achieve the expected outcomes. Unique identifier 6
7 Nursing treatments, actions and interventions Applicable across all perioperative settings Patient care focused Multiple activities Unique identifier 7
8 Outcomes Nursing Diagnosis Interventions Outcomes Transfer of care Interventions Assessment Nursing Diagnosis 8
9 Actual Nursing Care EHR Preop Intraop Postop Start End = Documentation of Nursing Care (PNDS) 9
10 Assessment Identifies physical alterations that require additional precautions I64 Verifies presence of prosthetic or corrective devices I127 Nursing Diagnosis Risk for perioperative positioning injury X40 Outcome Identification 05 The patient is free from signs and symptoms of injury related to positioning Implementation Positions the patient I96 Evaluation Evaluates for signs and symptoms of injury as a result of positioning I38 Outcome 05 The patient is free from signs and symptoms of injury related to positioning 24 years old Healthy Height 6 2 Weight 190 Male Procedure Right Inguinal herniorrhaphy Risk for impaired skin integrity X51 Risk for perioperative positioning injury X40 75 years old Frail Left side paralyzed - stroke Height 6 2 Weight 130 Male Procedure Right Inguinal herniorrhaphy Impaired physical mobility X34 Ineffective tissue protection X44 Ineffective tissue perfusion X61 10
11 PNDS I96 Positions the Patient Record Label Value Fill in the blank Documentation question to be answered The answer to the documentation question Drop down list Free text Provide reliable clinical data Comparison of clinical data from large number of patients/facilities Supports databases to measure outcome data, monitor & evaluate quality & effectiveness of care Supports benchmarking activities across settings & institutions Examination of the relationship of cost to quality Facilitate operational management 11
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