Analysis of a Locally Controlled Vocabulary in an Electronic Health Records for Evidence-Based Inpatient Fall-Prevention Care

摘要

A local controlled vocabulary provides a way to organize nursing documentation in electronic health record systems. However, a such vocabulary may not be always linked to standard nursing terminology or standard content. We explored a local nursing vocabulary set used in inpatient fall-prevention care at a large academic hospital with the aim of identifying if the standard nursing care was covered.