Nurses are routinely cast in the role of care coordinators making them an integral part of a patient’s health care plan. However, nursing documentation is not always sharable or comparable with data collected by other members of the care team.  

Nursing is uniquely positioned to recommend an interdisciplinary, shared terminology that allows nursing to be well-represented in the patient data across the continuum of care.

In April 2016, a national symposium of invited nurse leaders gathered at the University of Toronto. It was sponsored by the Canadian Nursing Association (CNA), with the participation of Canada Health Infoway, the Canadian Institute for Health Information and several vendors including Orion Health.  At this meeting, the following resolution was reached:

“CNA advocate for adoption of two standardised, clinical reference terminologies: SNOMED CT and ICNP as well as a standardised approach to nursing documentation in all clinical practice settings across Canada, specifically C-HOBIC and LOINC Nursing Physiologic Assessment Panel.”[i] 

The CNA Board ratified this proposal in its November 2016 Board meeting.

The second national symposium was recently held and organisers felt it was important to continue the dialogue and take steps towards adoption of clinical data standards across Canada. Orion Health was again on hand as a sponsor in these conversations, with Clinical Engagement Director Jeannette Polaschek and Managing Director Susan Anderson participating in the nursing practice and research working groups.

At the end of the event, there was unanimous endorsement by all participants of following standards for documenting Canadian nursing patient outcomes data:

  1. C-HOBIC standard for functional status, countenance, symptoms, safety, therapeutic self-care;
  2. LOINC nursing physiological assessment

Canadian nursing leaders are not alone in elevating the importance of common terminology and documentation standards for patient outcomes.   The U of Minnesota Nursing Program is preparing to host the fourth annual national Big Data Standards initiative this June. More about that initiative can be found here:

Overall, Orion Health is well positioned to expand use of adopted clinical terminology and nurse documentation standards by supporting its clients and technologies to facilitate sharing of patient data and outcome data across the continuum.  

[i] “Nurses Call for Standardized Clinical Terminology and Documentation”; Canadian Healthcare Technology, Apr 2017