Community Nursing Catalogue Development

One of the main advantages of an electronic patient record is the potential ability to re-use clinical information for service management and research purposes and to link with a range of evidence-based knowledge sources. However, in order to realise this benefit it must be possible to use standardised terminology for clinical documentation and data retrieval. Standardised terminologies equip clinicians with a way of describing their contribution to patient care using a structure and semantics which are acceptable to them. The choice of terminology depends on the clinical needs and professional groups involved.

Many areas of healthcare are becoming increasingly multidisciplinary focussed in approach. This may range from a ‘virtual’ team formed for specific patients, to totally integrated multidisciplinary teams who always work together. Clinicians working in these services currently may either use the medical orientated classifications which might not adequately describe their input to patient care or decide to use one or more of the profession or clinically specific terminologies. This raises issues about how to share and compare their contribution to the patient’s care.

Why should this matter? The different health professions each make a unique contribution to patient care and as a distinct profession it is important for nurses to be able to identify their specific contribution. What specific nursing issue was the focus of care ? What nursing interventions were used to address that issue? What were the patient outcomes as a result of that intervention? If these questions can be answered nurses will be able to articulate their input to a patient’s care even within a multidisciplinary record.

The International Reference Terminology Model was developed to recognise the diversity in profession or clinically specific terminologies and still allow comparison. This allows different terminologies, both nursing and larger health and medical terminologies, to be cross mapped for analysis purposes and supports the interchange of nursing data across systems.

The International Classification for Nursing Practice (ICNP®) is described as a unified nursing language system which facilitates cross-mapping of local terms and existing terminologies.

ICNP®) was selected by the Scottish Community Nursing Census because of:

• Flexibility: new items can be submitted to the ICNP® for addition to the classification.
• Comprehensive and adaptable: ICNP® can express nursing diagnoses, interventions, and outcomes.
• Transferability: other terminologies can be mapped to ICNP® and it is being mapped to SNOMED CT
• Comparability : ICNP® is used by a number of countries thus facilitating comparison of Scottish community nursing practice with practice in other countries.

The Census- ICNP® project currently underway aims to map the nursing problems and interventions used in the Scottish Community Nursing Census to ICNP® using a web-based mapping tool. A core group of practising community nurses will collaborate to ensure that the mapped terms are acceptable to community nurses in Scotland. Online validation will be invited from nurses and health informatics specialists.

Further information on this project is available from Alison Wallis