Terminology Mapping From Informatics and Nursing: Competencies and Applications Linda Q. Thede and Jeanne Sewell.

Terminology Mapping

From Informatics and Nursing: Competencies and Applications

Linda Q. Thede and Jeanne Sewell

If data is to be interchangeable among healthcare systems it is necessary to use a nationally accepted standardized terminology. There are however many different nationally accepted standardized terminologies.

Theoretically, one can enter terms in one nationally recognized standardized terminology which can then be translated by the system to another nationally recognized terminology in a process known as “mapping.”

Mapping

IllustrationIn this example, Nurse Stephanie in General Hospital is using the nationally accepted North American Nursing Diagnosis Association (NANDA-I) terms to enter nursing problems. Although she uses words to enter the terms, the system immediately translates the term to the appropriate code for NANDA-I.

General Hospital, however, stores data in its electronic healthcare record using the internationally accepted terminology SNOMED-CT.

To store the nursing problems charted by Stephanie it is necessary that the NANDA-I code be translated to the SNOMED-CT code. This is all done behind the scenes with no intervention from the user.This is accomplished using a mapping table that attempts to match the NANDA-I terms to concepts in SNOMED-CT.

Stephanie Documents

Stephanie is preparing a transfer report for Mrs. Anders whose care will be the responsibility of the local Visiting Nurse Association. One of Mrs. Anders problems is acute pain, which she enters into the electronic healthcare record.

Acute Pain

Systems Actions Behind Scenes (1)

Once Stephanie has entered the term “Acute Pain” the computer automatically translates that term to the code 00132 which is the code that NANDA-I uses to denote acute pain.

Acute Pain

becomes

00132

Systems Actions Behind Scenes (2)

Because General Hospital stores data using SNOMED-CT the NANDA-I code (00132) is “mapped” to the SNOMED-CT code for the concept Acute Pain (274663001).

00132

Mapped to

274663001

Systems Actions Behind Scenes (3)

The system now stores in Mrs. Anders chart the SNOMED_CT code 274663001 as a nursing problem.

274663001

System Retrieval Actions (1)Mrs. Anders is discharged to the Visiting Nurse Association (VNA) where the nurses use the Omaha System to document. Nurse Valerie is assigned to Mrs. Anders. Before making her first visit she retrieves the transfer record. The nursing problem acute pain is retrieved by the system as its SNOMED_CT code 274663001.

274663001

System Retrieval Actions (2)

The VNA system takes the SNOMED-CT code 274663001 for acute pain and using the mapping table translates the code to the Omaha System code for acute pain (24).

274663001

Mapped to

24

System Retrieval Actions (3)

The software on Valerie’s computer translates the code 24 to the term that Valerie recognizes “Acute Pain”

24

becomes

Acute Pain

System Retrieval Actions (3)

Acute Pain

Valerie sees the term “Acute pain” on her computer screen.

Mapping Accuracy

Mapping for clear cut concepts such as acute pain is fairly accurate. However, the translation is not always this easy and mapping may create some loss or change of meaning.

Review Storage

• Nurse enters NANDA Term• Without nurse effort:– System translates the term to the NANDA code for

that term– The NANDA code is mapped to the SNOMED-CT

code

• The system stores the SNOMED-CT code

Review Retrieval

• Nurse asks to see the record for Mrs. Anders• The system then– Retrieves the SNOMED-CT code– Maps it to the Omaha System code– Translates it to the actual term from the Omaha

System.• Valerie reads the Omaha System.

Review Concept

As far as Stephanie and Valerie are concerned they are communicating using the terminology with which they are familiar, while the system behind the scenes makes the necessary translations.