Healthc Inform Res.  2011 Sep;17(3):156-161. 10.4258/hir.2011.17.3.156.

Exploring the Possibility of Information Sharing between the Medical and Nursing Domains by Mapping Medical Records to SNOMED CT and ICNP

• So EY
• Park HA

• KMID: 1974241
• DOI: http://doi.org/10.4258/hir.2011.17.3.156

Abstract

OBJECTIVES
The purpose of this study is to explore possibility of information sharing between the medical and nursing domains.
METHODS
Narrative medical records of 281 hospitalization days of 36 gastrectomy patients were decomposed into single-meaning statements. These single-meaning statements were combined into unique statements by removing semantically redundant statements. Concepts from the statements describing patients' problem and medical procedures were mapped to Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) and International Classification for Nursing Practice (ICNP) concepts.
RESULTS
A total 4,717 single-meaning statements were collected and these single-meaning statements were combined into 858 unique statements. Out of 677 unique statements describing patients' problems and medical procedures, about 85.5% statements were fully mapped to SNOMED CT. The remaining statements were partially mapped. In the mapping to the ICNP concepts, 17.4% of unique statements were fully mapped, 62.8% were partially mapped, and 19.8% were not mapped. About 32.3% of 705 concepts extracted from the statements were mapped to both SNOMED CT and ICNP concepts.
CONCLUSIONS
These mapping results suggest that physicians' narrative medical records can be structured and can be used for electronic medical record system, and also it is possible for medicine and nursing to share patient care information.

Keyword

Information Management; Medical Records; Controlled Vocabulary; Systematized Nomenclature of Medicine; International Classification for Nursing Practice

MeSH Terms

Electronic Health Records
Gastrectomy
Hospitalization
Humans
Information Dissemination
Information Management
Medical Records
Patient Care
Systematized Nomenclature of Medicine
Vocabulary, Controlled