Question about standardizing data

[jlao]

Hopefully I can have some feedback from other informatics nurses out there.

My facility is currently using an EHR system but the way data captured is not standardize. Most of the documentation is free text. If there are areas of choosing from check boxes, I believe there is no standard or guide line dictating the choices. I know there are guidelines of terminology like SNOMED CT. I used Snowflake, which is a search browser for SNOMED CT terms. I am having a hard time finding standards for description.

Example:

A nurse is charting about urine output and wants to describe the color. Is there a standard for this description? A nurse can describe this in so many ways. I tried looking through SNOMED CT and could not really find this in there through the Snowflake search browser. Any help would be great!

[mariafh]

SNOMED CT will not define what should be charted about urine output and its color. SNOMED CT main purpose is to tag the data that is charted so that it can be understood and later used for analysis. So SNOMED CT will not provide you the choice list of colors for urine output. Once the user selects a color, the concepts of urine output and the color value can be tagged with individual SNOMED CT codes. If you are looking for documentation standards for urine output and its color, it would be found in other resources. One might consider looking at the IHI Home Page, The Institute for Healthcare Improvement on their CAUTI bundle which may describe documentation of urinary catheter and perhaps urine output. Others may suggest other standards and resources to use. In general, SNOMED CT and similar terminologies will not describe what should be charted for observations, only provide a way to identify the data.