Representation of Diagnosis and Nursing Interventions in OpenEHR ArchetypesFunding M.R.C. reports grants from Conselho Nacional de Desenvolvimento Científico e Tecnológico, Brazil during the conduct of the study. D.C.G. reports grants from Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (Capes) (financing code 001) during the conduct of the study.
Objective The study aimed to represent the content of nursing diagnosis and interventions in the openEHR standard.
Methods This is a developmental study with the models developed according to ISO 18104: 2014. The Ocean Archetype Editor tool from the openEHR Foundation was used.
Results Two archetypes were created; one to represent the nursing diagnosis concept and the other the nursing intervention concept. Existing archetypes available in the Clinical Knowledge Manager were reused in modeling.
Conclusion The representation of nursing diagnosis and interventions based on the openEHR standard contributes to representing nursing care phenomena and needs in health information systems.
Keywordsnursing informatics - health information interoperability - standardized nursing terminology - nursing notes - patient records
Protection of Human and Animal Subjects
Received: 02 December 2020
Accepted: 09 March 2021
14 April 2021 (online)
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