KMID : 0603720110170030156
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Journal of Korean Society of Medical Informatics 2011 Volume.17 No. 3 p.156 ~ p.161
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Exploring the Possibility of Information Sharing between the Medical and Nursing Domains by Mapping Medical Records to SNOMED CT and ICNP
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So Eun-Young
Park Hyeoun-Ae
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Abstract
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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.
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KEYWORD
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Information Management, Medical Records, Controlled Vocabulary, Systematized Nomenclature of Medicine, International Classification for Nursing Practice
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