Stichting VDIR

In Dutch healthcare, electronic nursing care plans are increasingly established through Standardized Nursing Languages (SNLs) like Omaha System (OS) and NANDA-I, NIC and NOC. International developments promote the exchange and secondary use of health information, which requires interoperability of health data. SNLs are potentially interoperable due to their standardized and coded format and can be integrated into electronic health records (EHRs). New Dutch legislation and the European Health Data Space Act mandate the use of SNOMED CT for information exchange. Therefor the Dutch Nursing Association (V&VN) and the Dutch National institute for IT in Healthcare (Nictiz) developed a Dutch Nursing SNOMED CT Subset (DNSS) of patient problems. However, SNOMED CT and SNLs have different objectives: SNLs aim to support clinical reasoning and documentation of nursing care, while SNOMED CT aims to provide a global medical vocabulary to enable communication between EHR systems and analysis of information. To enable nurses use of their preferred SNL for primary documentation in the EHR, and exchange information with SNOMED CT a mapping is required between SNLs and SNOMED-CT. This mapping was executed by a working group with OS and NANDA-I experts, V&VN representatives and Nictiz terminology experts. Similarities and differences in structure and semantic content of DNSS, OS, and NANDA-I were examined to investigate the possibility of exchange of information between OS, NANDA-I and the DNSS of patient problems, and the consequences for information loss.