Abstract
BACKGROUND
The UK health visiting service provides a universalist preventive health service that focuses mainly on families with young children and the elderly or vulnerable, but anyone who wishes can access the services. The principles of health visiting have been formally defined as the search for health needs, the stimulation of awareness of health needs, influencing policies that affect health, and the facilitation of health-enhancing activities.
The project is currently in its fourth phase. In phase 1, 17 health visitors recorded their encounters with families with new babies over a period of 3 months; in phase 2, 27 health visitors recorded their encounters with a wider range of clients (769 encounters with 205 families) over a period of 9 months; in phase 3, the system is being used by a variety of healthcare professionals in a specialist program that provides intensive parenting support; phase 4 is developing a prototype of an automated version for point-of-contact recording.
UK nursing has no tradition of standardized language and the concept of nursing diagnosis is almost unknown. Over the past decade, however, the government has initiated the development of a standardized terminology (Read codes) to cover all disciplines and all aspects of health care, and it is likely that the emerging SNOMED-CT terminology (a merger of the Read codes with the SNOMED terminology) will be mandated for use throughout the National Health Service (NHS).
MAIN CONTENT POINTS
The structure and key elements of the Omaha System were retained but the terminology was modified to take account of the particular field of practice and emerging UK needs. Modifications made were carefully tracked. The Problem Classification Scheme was modified as follows:
All terms were anglicized. Some areas — notably relating to antepartum/postpartum, neonatal care, child protection, and growth and development—were expanded. The qualifiers “actual,”“potential,” and “health promotion” were changed to “problem,”“risk,” and “no problem.” Risk factors were included as modifiers of “risk” alongside the “signs and symptoms” that qualify problems.
The Intervention Classification was modified by substituting synonymous terms for “case management” and “surveillance” and dividing “health teaching, guidance, and counseling” into two categories. The Omaha System “targets” were renamed “focus” and a new axis of “recipient” was introduced in line with SNOMED-CT.
The revised terminologies were tested in use and also sent for review to 3 nursing language experts and 12 practitioners, who were asked to review them for domain completeness, appropriate granularity, parsimony, synonymy, nonambiguity, nonredundancy, context independence, and compatibility with emerging multiaxial and combinatorial nomenclatures. Review comments were generally very favourable and modifications suggested are being incorporated.
CONCLUSIONS
The newly published government strategy for information management and technology in the NHS in Wales requires the rapid development of an electronic patient record, for which the two prerequisites are structured documentation and the use of standardized language. The terminology developed in this project will enable nursing concepts to be incorporated into the new systems. The experiences of the project team also offer many lessons that will be useful for developing the necessary educational infrastructure.
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