| Summary: | Documentation is a professional responsibility in nursing because it facilitates communication, promotes good nursing care, and acts as a valuable method to demonstrate that legal and agency standards are followed. Nurses are increasingly using health information technologies, such as electronic health records, to document care. To be able to measure and compare the impact of nursing on patient outcomes, standardized clinical terminologies compliant with international standards are necessary. In British Columbia, Canada, nurses use a standardized wound care template to document their assessments and the care they provide to patients; however, the content of this assessment is currently not shared in a computable format between different electronic health records within the province. The purpose of this thesis was to map wound care data elements from the BC Standardized Nursing Wound Documentation standard to SNOMED-CT. To complete this “bottom-up” mapping activity, creation of a conceptual model of knowledge representation for nursing wound care was developed to inform three concurrent methods of mapping (manual, automated, and literature comparison) for 107 data elements. These methods produced candidate lists, which were reviewed by two expert wound care clinicians who created an expert consensus list. Results of this expert consensus list indicated that 40.2% of the terms had direct matches, 1.9% had one-to-many matches, and 57.9% had no matches. The outcome of this study was the creation of a conceptual model of nursing knowledge representation for wound care, a list of mapped wound care data elements to SNOMED-CT, identification of missing and duplicate concepts in SNOMED-CT, and application of concurrent mapping methods to inform the creation of an expert consensus list. The advancement of standardized clinical terminologies to support semantic interoperability between disparate electronic health records is an important measure to ensure patient information is shared throughout the continuum of care. This thesis work provides a method to incorporate local nursing standards into SNOMED-CT, with the intent to ensure that nursing care is represented. === Applied Science, Faculty of === Nursing, School of === Graduate
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