Using the Omaha System for Clinical Documentation

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Using the Omaha System for Clinical Documentation

• Kathy H. Bowles PhD, RN
• Associate Professor
• University of Pennsylvania

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Why Vocabulary/Classification

• If we cannot name it, we cannot control it,
• finance it, research it, teach it, or put it into
  public policy.
• Dr. Norma Lang
• (International Council of Nurses, 1993, p.2)

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Information Management Problems

• Information overload
• Delay in relay of information
• Necessary information not available
• Available information not accessible
• Accessible information not usefully organized

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Could You Answer These Questions?

• What does an RN or an APN do that a less
  expensive provider could not do?
• How do you care for dementia patients?
• What are the most frequent patient problems that
  you encounter in your patient population?

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Old Assumptions

• No longer true that client needs are related to a
  medical diagnosis alone
• todays clients have
• complex functional problems with multiple
  co-morbid conditions in an uncertain environment
  with
• varying support systems

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A stroke, is not a stroke, is not a stroke
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LOINC
NMMDS
Perioperative Nursing Data Set
ABC Codes
Omaha System
Patient Care Data Set
Home Healthcare Classification
NMDS
SnomedRT
ICNP
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The Omaha System

• A research-based, comprehensive and standardized
  taxonomy designed to enhance practice,
  documentation, and information management.
• Comprised of three components
• Problem Classification Scheme
• Intervention Scheme
• Problem Rating Scale for Outcomes

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The Omaha System

• Omaha System work began in 1970 at the VNA of
  Omaha
• Between 1975 -1986 three research studies were
  completed to develop and refine the system
• 1989-1993 further research addressed reliability,
  validity, and usability
• Over 40 studies completed over the last 30 years
• Used in 169 organizations by 8,000 employees and
  in 14 countries

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The Omaha System

• Congruent with the ISO standards, JACHO and
  community health accreditation program
• Included in the NLM metathesaurus, SNOMED CT, and
  the ANSI HISB Inventory of Clinical information
  standards
• Indexed in CINAHL and recognized by HL7 and
  integrated into LOINC

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Problem Classification Scheme

• Four Domains
• ENVIRONMENTAL
• PSYCHOSOCIAL
• PHYSIOLOGICAL
• HEALTH RELATED BEHAVIOR

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Problem Classification Scheme

• Environmental Domain Material resources and
  physical surroundings both inside and outside the
  living area, neighborhood, and broader community.
• IncomeSanitationResidenceNeighborhood/workplace
  safety

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Problem Classification Scheme
Psychosocial Domain Patterns of behavior,
emotion, communication, relationships, and
development.

• Communication with community resourcesSocial
  contactRole changeInterpersonal
  relationshipSpiritualityGrief

• Mental healthSexualityCaretaking/parentingNegl
  ectAbuseGrowth and development

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Problem Classification Scheme
Physiological Domain Functions and processes
that maintain life.

• HearingVisionSpeech and languageOral
  healthCognitionPainConsciousnessSkinNeuro-mus
  culo-skeletal function

• RespirationCirculationDigestion-hydrationBowel
  functionUrinary functionReproductive
  functionPregnancyPostpartumCommunicable/infecti
  ous condition

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Problem Classification Scheme

• Health Related Behaviors Domain Patterns of
  activity that maintain or promote wellness,
  promote recovery, and decrease the risk of
  disease.
• NutritionSleep and rest patternsPhysical
  activityPersonal careSubstance useFamily
  planningHealth care supervisionMedication
  regimen

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Intervention Scheme

• Four broad categories of interventions appear at
  the first level.
• An alphabetical list of 75 targets or objects of
  action and one other appear at the second
  level.
• Client-specific information generated by
  practitioners is at the third level.
• enables practitioners to describe and communicate
  their practice including improving or restoring
  health, decreasing deterioration, or preventing
  illness.

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Intervention Scheme

• Teaching, guidance, and counseling
• Treatments and procedures
• Case Management
• Surveillance

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Intervention Scheme Targets

• anatomy/physiologyanger managementbehavior
  modification bladder care bonding/attachment
  bowel care cardiac care caretaking/parenting
  skills cast care communicationcommunity
  outreach worker servicescontinuity of care
  coping skills day care/respitedietary
  management discipline

• dressing change/wound care durable medical
  equipment education employmentend-of-life care
  environment exercises family planning care
  feeding procedures finances gait
  traininggenetics growth/development care home
  homemaking/housekeeping

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Example

• Nutrition
• Signs and symptoms
• weighs 10 less than average
• unbalanced diet
• Case management
• Target
• Nutritionist care
• Surveillance
• Target
• Feeding procedure

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Problem Rating Scale for Outcomes
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Applying the Omaha System

• 8.6 problems/patient (range 3-25)
• 8 environmental
• 19 psychological
• 46 physiological
• 27 health related behavior

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Patient Problems

• 43 emotional stability
• 43 prescribed medication regimen
• 40 pain
• 37 neuromusculoskeletal
• 37 respiration

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Prescribed medication regimen

• 23 drug side effects
• 6 polypharmacy
• 6 medication non-adherence

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Nursing Interventions N7000
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Nursing Interventions for Discharge Planning
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Resources

• www.omahasystem.com
• Martin KS. (2005). The Omaha System A Key to
  Practice, Documentation, and Information
  Management (2nd ed.) St. Louis Elsevier.