Gap Analysis and Refinement Recommendations of Skin Alteration and Pressure Ulcer Enterprise Reference Models against Nursing Flowsheet Data Elements

摘要

Reference models are an essential instrument to provide structure and guidance in the creation and use of data elements within an organizations’ electronic health record (EHR). Standardization of data elements is imperative to ensure clinical data is consistently and reliably captured for use in clinical documentation, care communication, and a variety of downstream data uses. Ongoing assessment and refinement of reference models and data elements are necessary to ascertain clinical data capture is applicable and inclusive across a variety of caregivers and domains. We performed a gap analysis on current state nursing data elements against two validated interprofessional reference models: skin alteration and pressure ulcer assessments. We present our findings along with recommendations for reference model refinements. We also highlight additional findings of inconsistencies and redundancies within data elements used for nursing documentation and highlight recommendations for improvement.