Community Healthcare and Electronic Nursing Documentation

Abstract

The management of electronic health records (EHRs) and the use of these data to detect the patients’ complexity in a community healthcare context. The aim of this study is to develop a nursing diagnosis (ND) subset (International Classification for Nursing Practice-ICNP or NANDA-I) implemented in the Health Community Digital Platform (HCDP) used to manage the public health system in the Lombardy Region, Italy. From the HCDP sections, we extracted a training data subset by considering: Access Reports, Multidimensional Evaluations, Diary, Appointments, Volume Summary and Team Management. We studied an amount of 1465 health accesses, 980 social accesses and 1,006 accesses requiring further examination, then we identified and labeled 3,451 NDs, by consulting the breakdown of the sections. Nursing-generated data collected by the platform will be used to monitor patients’ complexity: the learning models development, requires a strong integration between nursing specific knowledge and Artificial Intelligence (AI) technology. Nurses and engineers should understand the relationship between the data they collected and how the AI can contribute to give them solutions.