Strukturering og standardisering af sygeplejefaglig dokumentation indenfor ernæring vha. SNOMED CT

Abstract

Underernæring er et område, hvor der er evidens for at en målrettet ernæringsindsats bidrager til et mere effektivt behandlingsforløb. Området er understøttet af kliniske standarder, som i fremtiden skal akkrediteres gennem journalaudits. Sygeplejedokumentationen er karakteriseret ved en lav struktureringsgrad, hvilket vanskeliggør gennemførelsen af journalaudits. IT udgør fremtidens dokumentationsværktøj, hvilket åbner for muligheder for at strukturere og standardisere dokumentationen for lettere at kunne genfinde og genbruge data. Til at opnå standardiserede data er det besluttet at anvende SNOMED CT. I dette projekt undersøges det, hvorledes dokumentationen indenfor ernæring kan struktureres og standardiseres, således at klinisk praksis understøttes bedst muligt. Dokumentationspraksis indenfor ernæring undersøges vha. journalanalyser og interviews. De strukturerede kliniske udtryk mappes dernæst til SNOMED CT, og implementeres i et IT-system, hvor det ønskes afprøvet, hvorvidt struktureringen understøtter dokumentationen i klinisk praksis. Der er valgt en struktureringsgrad, hvor data omhandlende faktuelle og eksakte informationer beskrives i en højt struktureret form, mens data afspejlende den enkelte patient gennem empati og kommunikation beskrives i en lav struktureringsgrad. Mapningen af de strukturerede udtryk til SNOMED CT gøres primært vha. postkoordineringer. Gennem afprøvningen af strukturering vha. det udviklede IT-system kan det konkluderes, at denne er anvendelig, men at det vil kræve vaneændringer at indføre i klinisk praksis. Samtidig kan det konkluderes, at mapningen af de kliniske udtryk kræver stor klinisk forståelse, og der en behov for at gøre udtrykkene mere entydige, således at disse er velegnet til at mappe. Dette har indflydelse på andelen af kliniske udtryk mappet til SNOMED CT.

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.

A master thesis from Aalborg University

Strukturering og standardisering af sygeplejefaglig dokumentation indenfor ernæring vha. SNOMED CT

[Structured and standardised nursing documentation of nutrition care by means of SNOMED CT]