© Schattauer 2011 304 Applied Clinical Informatics O. Farri, K.A. Monsen, B.L. Westra, G.B. Melton: Analysis of Free Text with Omaha System Targets in Community-Based Care Research article Analysis of Free Text with Omaha System Targets in Community-Based Care to Inform Practice and Terminology Development O. Farri 1 ; K.A. Monsen 1 ; B.L. Westra 1 ; G.B. Melton 1 1 University of Minnesota, Minneapolis Keywords Interface terminology, Omaha system, Content coverage, community health care, nursing assess- ment Summary The Omaha system is one of the most widely used interface terminologies for documentation of community-based care. It is influential in disseminating evidence-based practice and generating data for health care quality research. Thus, it is imperative to ensure that the Omaha system re- flects current health care knowledge and practice. The purpose of this study was to evaluate free text associated with Omaha system terms to inform issues with electronic health record system use and future Omaha system standard development. Two years of client records from two diverse sites (a skilled homecare, hospice, and palliative care program and a maternal child health home visiting program) were analyzed for the use of free text as a component of the intervention when struc- tured targets for interventions were not identified. Intervention text entries very commonly con- tained duplicate “carry forward entries”, multiple concepts, mismatched problem focus, or failure to identify an existing appropriate target. Our findings support the need to better address edu- cation gaps for clinicians. We identified additional suggested targets for Omaha system problems, and propose new targets for consideration in future Omaha system revisions. Correspondence to: Genevieve B. Melton, MD, MA, FACS Assistant Professor, Department of Surgery Faculty Fellow, Institute for Health Informatics University of Minnesota 420 Delaware Street SE; MMC 450 Minneapolis, MN 55455 Telephone: 612–625–7992; Fax: 612–625–4406 Email: gmelton@umn.edu Appl Clin Inf 2011; 2: 304–316 doi:10.4338/ACI-2010-12-RA-0077 received: December 30, 2010 accepted: April 10, 2011 published: August 10, 2011 Citation: Farri O, Monsen KA, Westra BL, Melton, GB: Analysis of free text with Omaha system targets in community-based care to inform practice and ter- minology development. Appl Clin Inf 2011; 2: 304–316 http://dx.doi.org/10.4338/ACI-2010-12-RA-0077 This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.