Representation of Diagnosis and Nursing Interventions in OpenEHR Archetypes
Denilsen Carvalho Gomes
1
Graduate Program in Health Technology, Pontifícia Universidade Católica do Paraná,
Curitiba, Brazil
,
Nuno Abreu
2
Department of Medicine, Centro Hospitalar Universitário do Porto, Porto, Portugal
,
Paulino Sousa
3
Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty
of Medicine, University of Porto, Porto, Portugal
,
Claudia Moro
1
Graduate Program in Health Technology, Pontifícia Universidade Católica do Paraná,
Curitiba, Brazil
,
Deborah Ribeiro Carvalho
1
Graduate Program in Health Technology, Pontifícia Universidade Católica do Paraná,
Curitiba, Brazil
,
Marcia Regina Cubas
1
Graduate Program in Health Technology, Pontifícia Universidade Católica do Paraná,
Curitiba, Brazil
› Author Affiliations Funding 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.
Keywords
nursing informatics -
health information interoperability -
standardized nursing terminology -
nursing notes -
patient records
Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany
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