• Anne-Mette Lindgaard
  • Pia Andersen
Within the field of malnutrition evidence exist, that the use of nutrition support contributes to a more efficient and effective course of treatment. Clinical standards form the underlying basis of accreditation by means of an audit process in the future. The nursing documentation is characterized by low-level data which complicates the audit process. The implementation of IT in the health care sector facilitates a potential for obtaining structured and standardised data in order to reuse and exchange clinical information. To achieve standardised data it has been decided to use SNOMED CT. This project investigates how it is possible to structure and standardise the nursing documentation of nutrient care so that clinical practice is supported in the best possible way. Nursing documentation of nutrient care in clinical practice is investigated through analysis of patient records and interviews. Structured clinical expressions are mapped to SNOMED CT and implemented in an IT-system. Based on the IT-system, a user test investigates the ability of the structured expressions to support the clinical need for documentation. The nursing documentation is structured in a way where data containing factual and exact information is highly structured and clinical information based on empathy and communication is described in a low-level structure. The structured clinical expressions are primarily mapped to SNOMED CT by postcoordination. On the basis of the user test by means of the IT-system it can be concluded that the structured clinical expressions are usable but changed habits are required in order the be implemented in clinical practice. It can be concluded that mapping clinical expressions requires a huge understanding of clinical practice and there is a need for stating the expressions in a more precise way so that the expressions are suitable for mapping. This problem influence the number of expressions mapped to SNOMED CT.
Publication date2009
Number of pages203
Publishing institutionAalborg Universitet
ID: 17646246