Observational (n=491)
Structuring nursing documentation for myocardial infarction patients using SNOMED CT reveals that observation of patient condition and taking vital signs are the most frequently documented domains and concepts.
This study aims to analyze unstructured nursing documentation of myocardial infarction patients using clinical practice guidelines and SNOMED CT. A total of 72,234 records from 491 patients were annotated using 17 domains derived from the CCCN and AHA/ACC CPGs and mapped to SNOMED CT. The most frequent concepts were "Taking patient vital signs (procedure)" (n = 4,432), and the most frequent domain was observation of patient condition (n = 31,181, 43%).
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Lee et al. (2026) conducted an observational in Myocardial Infarction (n=491). Structuring nursing documentation using clinical practice guidelines and SNOMED CT was evaluated on Frequency of concepts and domains mapped to SNOMED CT. Structuring nursing documentation for myocardial infarction patients using SNOMED CT revealed that observation of patient condition was the most frequent domain (43% of records).
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