Nursing Documentation Program Support
To aid in standardizing terms with common meanings used by nurses to facilitate the exchange of Electronic Health Records, J P System evaluates and matches medical terms for the VHA Office of the Chief Nursing Informatics Officer (OCNIO). The project focuses on mapping of the identified VHA Nursing Domain terms for skin wounds including nursing assessment, interventions and patient outcomes. It also focuses on mapping of Clinical Care Classification (CCC) System terminology for skin integrity including Care Components, Nursing Diagnosis, Nursing Intervention, Nursing Actions and Outcomes.
In addition, J P Systems provides a crosswalk of the associated new domain terminology mappings as well as low and high complexity terminology consultations. The project focuses on the analysis of the current nursing terminology management strategy and creates a plan for implementation of new terminology managing. This will ultimately provide a strategy for integration of a new standardized nursing terminology taxonomy as the basis for nursing documentation across the VHA enterprise. A pilot project will focus on Pressure Ulcer (PU) observations which involves the identification of a PU Minimum Data Set (MDS). The data will then be used as a basis for the consultation efforts directed towards the evaluation of the appropriate information model.