I’m Evelien and works in The Netherlands as CNIO (Chief Nursing Information Officer) in the elderly care (home care).
For a project about SNOMED CT coding of nursing diagnoses and the classifications system (Nanda and Omaha) i have a question to this group. Does someone used a archetype at this moment for Nursing Diagnosis (Risk, Current and prevention)? It doesn’t seem to fit in the archetype ‘Problem diagnosis’.
Currently I don’t think we have one single archetype that fits the whole spectrum of nursing diagnoses, especially if we’re including the “positive” diagnoses used for goals, evaluations and outcomes. I don’t know the Omaha system too well, but I’m fairly familiar with ICNP which I think is similar.
For most of the “actual” and “negative” diagnoses, I think Problem/diagnosis is fine, and for “potential” probably Health risk assessment. For “positive” diagnoses I think we only have Goal right now at a generic level. For “family” and “community” diagnoses I think we could maybe use Family history and related archetypes, as well as several of the archetypes in the Social context project.
I agree with this @siljelb I would say that the problem/diagnosis archetype is a pretty good for most of the categories - perhaps each category templated separately.
I’d also agree re Goal as a seperate archetype but I’d want to understand how the other categories e.g. family history /community are expected to work in the context of the wider record.
There might be an argument for just leaving family history / community diagnoses as simple codes in the Nursing diagnosis, if they are contextual to a nursing plan and not ‘authoritative’ to the overall record.
