Under många år har journalföring i vården varit bristande, då det inte sällan dokumenteras i egna moduler och på fritext. Detta gäller även för dokumentation av omvårdnad. Användning av ICNP i Snomed CT ger förutsättningar för ett standardiserat och systematiskt sätt att dokumentera och följa upp omvårdnad – exempelvis omvårdnadsdiagnoser, -åtgärder och -resultat. Dessutom kan användning av ICNP i Snomed CT ge ökade möjligheter till forskning och verksamhetsutveckling, återanvändning av dokumenterade information mellan olika professioner och således ökad patientsäkerhet.
Förra året presenterade Socialstyrelsen och Svensk sjuksköterskeförening om ett pågående samarbete utifrån ett avtal mellan International Council of Nurses och SNOMED International om att ICNP ska ingå som en del av Snomed CT. I denna presentation presenteras inledande erfarenheter och resultat av detta samarbete med fokus på en kvalitetsgranskad översättning av ICNP i den svenska utgåvan av Snomed CT. Utöver detta kommer deltagare att få information om hur samverkan kring den omvårdnadsterminologin har sett ut, både internationellt och nationellt, och vad som förväntas fortsättningsvis.
Jag heter Erica Culp och jobbar på Socialstyrelsen som hälsoinformatiker och projektledare. Jag har en bakgrund som legitimerad sjuksköterska, både i Sverige och i USA. Nu arbetar jag med förvaltning av ett av Socialstyrelsens e-hälsoverktyg – Snomed CT. Mitt intresse är att medverka till att utveckla och förbättra användning av strukturerad, enhetlig och entydig vårdinformation inom hälso- och sjukvård.
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