The Adequacy of ICNP Version 1.0 as a Representational Model for Electronic Nursing Assessment Documentation

Abstract

A b s t r a c t Objectives:The purpose of this study was to evaluate the adequacy of the International Classification of Nursing Practice 1 (ICPN) Version 1.0 as a representational model for nursing assessment documentation. Design and Measurements:To identify representational requirements of nursing assessments, the authors mapped key concepts and semantic relations extracted from standardized and local nursing admission assessment documentation forms/templates and inpatient admission assessment records to the ICNP. Next, they expanded the list of ICNP semantic relations with those obtained from the admission assessment forms/templates. The expanded ICNP semantic relations were then validated against the semantic relations identified from an additional set of admission assessment records and a set of 300 randomly selected North American Nursing Diagnosis Association defining characteristic phrases. The concept coverage of the ICNP was evaluated by mapping the concepts extracted from these sources to the ICNP concepts. The UMLS Methathesaurus was then used to map concepts without exact matches to other American Nursing Association (ANA) recognized terminologies. Results:The authors found that along with the 30 existing ICNP semantic relations, an additional 17 are required for the ICNP to function as a representational model for nursing assessment documentation. Eight hundred and five unique assessment concepts were extracted from all sources. Forty-three percent of these unique assessment concepts had exact matches in the ICNP. An additional 20% had matches in the ICNP classified as narrower, broader, or "other." Of the concepts without exact matches in the ICNP, 81% had exact matches found in other ANA recognized terminologies. Conclusions:The broad concept coverage and the logic-based structure of the ICNP make it a flexible and robust standard. The ICNP provides a framework from which to capture and reuse atomic level data to facilitate evidence-based practice. Ⅲ J Am Med Inform Assoc. 2009;16:238 -246. DOI 10.1197/jamia.M2956. IntroductionAs health care organizations transition from paper to electronic clinical documentation systems, it is vital that consideration be given to representing nursing data in ways that are sharable and that preserve the complexity, context, and richness of patient care. Standard vocabularies provide unambiguous and consistent representation of data for sharing and reuse, 2 but multiple vocabularies are needed to represent the complexity and variation that exist across domains of practice and levels of care.3-5 Many members of the American Nursing Association (ANA) recognize that nursing vocabularies include lists of terms that were created to describe a particular domain of nursing practice.a These vocabularies are important because they ensure that diverse domains of nursing practice are represented. However, in addition to providing a rich set of atomic concepts, formal coordination rules are needed to support representation of more complex concepts. The concept coordination r...

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