Abstraction of Nursing Minimum Data Set Elements from Special Care Nursery Records
Kirkhof College of Nursing
The Nursing Minimum Data Set (NMDS) was described by Werley (1988) for purposes of creating data repositories that include nursing information to support a wide variety of research objectives. However, evidence is needed to determine the usefulness of the NMDS in abstracting data from electronic health records (EHRs) to enable the mining of data that advances nursing science. This study used the NMDS to describe nursing care delivered to infants hospitalized in Special Care Nurseries in a community hospital system. Partially de-identified care plan and demographic data downloaded from the inpatient EHRs of 259 ill newborns provided specialized nursery care between February 1 and March 31, 2011 across eleven hospitals in the Midwest. Using Werley s NMDS abstraction tool and a codebook of the variables of interest, the nursing diagnoses, goals, activities, and progress to goals, were explored for the SCN care plans. Descriptive analyses were completed. The count of nursing diagnoses per infant ranged from 0 to 19 (Median =6). Goals were identified for 142 caregiving encounters. Activities and goals could not always be linked to unique diagnoses because of use across several diagnoses and the nurses use of free text during documentation. Additionally, routine care activities were sometimes evident without corresponding diagnoses because they were required by documentation policies. Most items of the NMDS were extractable from care plans, but other portions of the EHR (e.g., flowsheets) may contain other NMDS elements important to researchers. Nurse scientist leadership in designing electronic documentation systems is essential to support research in caregiving processes.
Midwest Nursing Research Society Annual Conference
Coviak, Cynthia; Westra, Bonnie; Collins, Beverly; Olsen, Cathy; Fletcher, Linda; Sharma, Deepika; Swanberg, Heather; and Monson, Karen, "Abstraction of Nursing Minimum Data Set Elements from Special Care Nursery Records" (2011). Faculty Scholarly Dissemination Grants. 450.