Structural Data Elements — Standardized Terms and Definitions

AORN Journal, March, 2000 by Suzanne C. Beyea

To achieve these goals, the AORN Board of Directors established the Task Force on Perioperative Data Elements in November 1993. Fourteen expert perioperative nurses, including staff nurses, nurse managers, computer/informatics specialists, and nurse researchers, began the process of defining the elements of the database.

Task Force members believed that a standardized nursing language would provide a structured vocabulary and, thus, a common means of communication. Identifying terms that were clear, precise, and consistent and that described nursing care in the perioperative setting was an essential part of the process. Another critical step was explicating the dimensions of professional nursing practice in the perioperative setting. The work of Task Force members was guided by the premise that language development would help perioperative nurses document the care they gave while providing a foundation for examining and evaluating the quality and effectiveness of that care. Group members decided to develop a unified data set, rather than a uniform data set, which allowed various terms to be used for the same or similar activities (eg, bovie versus cautery).

The Task Force accepted the recommendations of Harriet Werley and colleagues to extend the Medicare Uniform Hospital Discharge Data Set, so the framework chosen for data collection and language development was the Nursing Minimum Data Set (NMDS).(1) Task Force members chose four key components of the NMDS to focus future work, which included nursing diagnoses, nursing interventions, nursing outcomes, and intensity of nursing care. The group adopted Norma Lang's motto, "If we cannot name it, we cannot control it, finance it, teach it, research it, or put it into public policy."(2)

A standardized language consists of a collection of data elements. In the PNDS, the data elements include perioperative nursing diagnoses, interventions, and patient outcomes. Subcommittee efforts also addressed related data elements such as structural definitions. A data element is a "unit of data for which the definition, identification, representation and permissible values are specified by means of a set of attributes."(3) Data elements are characterized by being the smallest unit of information that retains meaning (eg, raw fact, material, observation). Each data element is a discrete component that describes the concept without requiring further interpretation or information.

Data elements allow for standardization of a language and also permit the language to be managed in an electronic format. Patient-specific information in the medical record is a database that consists of data elements. Defining data elements at an atomic level allows information to be managed in computer software and automated databases. The DECC focused on identifying data elements that defined and described nursing activities that contribute to patient outcomes in the perioperative setting. When these individual data elements were combined, they provided the framework for the PNDS.