Developing Structured Omaha System Goals for Use in an Electronic Health Record

Ann M. O'Neill, Michael R. Mossing, Marci D. Newcome, Kari B. Miller, Karen A. Monsen

Research output: Contribution to journalArticle

Abstract

Use of standardized terminology has been essential for clear, concise, and accurate documentation of client assessments, care plans, and outcomes. The purpose of this study was to create standardized language goals for a case management system that used the Omaha System. A group of nursing informaticists analyzed, refined, and developed revised goals evaluated using medical vocabulary properties. A set of unique goals aligned with the Omaha System was developed with specifically designed characteristics and functionality that allowed individualization and evaluation of goal attainment. Goal statements and ratings were standardized and written to reflect goals a client could attain. The Omaha System goals served as a template for nurse case managers to use in telephonic support with clients and future development of new goals and allowed the organization the ability to generate quality metrics.

Original languageEnglish (US)
Pages (from-to)655-661
Number of pages7
JournalCIN - Computers Informatics Nursing
Volume37
Issue number12
DOIs
StatePublished - Dec 1 2019

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Keywords

  • Goals
  • Knowledge representation
  • Omaha System
  • Standardized terminology

PubMed: MeSH publication types

  • Journal Article

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