The Omaha System PDF

THE OMAHA SYSTEM Dr. Meryem ERCEYLAN The Omaha System ◦ The Omaha System is a research-based, comprehensive practice and documentation standardized taxonomy designed to describe client care. ◦ Users are increasingly diverse, and represent the continuum of care in practice, education, research, and c...

THE OMAHA SYSTEM Dr. Meryem ERCEYLAN The Omaha System ◦ The Omaha System is a research-based, comprehensive practice and documentation standardized taxonomy designed to describe client care. ◦ Users are increasingly diverse, and represent the continuum of care in practice, education, research, and community settings. The Omaha System ◦ There are more than 22,000 individuals used the Omaha System in the United States and around the World ◦ The number and type of software developers who offer computerized versions of the Omaha System continue to grow. History ◦ Work on the Omaha System began in the 1970s when Visiting Nurse Association (VNA) of Omaha (Nebraska) staff began revising their home health and public health client records and adopting a problem-oriented approach. ◦ The goal was to provide a useful guide for practice, a method for documentation, and a framework for information management. History ◦ Between 1975 and 1986, three research projects were conducted to develop and refine the Omaha System. ◦ Between 1989 and 1993, further research designed to establish reliability, validity, and usability was conducted. ◦ During the early years, information was disseminated through workshops and speeches. ◦ The first Omaha System article was published in 1981, ◦ The first books in 1992, and the current book in 2005. The Omaha System The American Nurses Association recognized the Omaha System as a standardized terminology to support nursing practice in 1992. In 2014, Minnesota became the first state to recommend ANArecognized point-of-care terminologies be used in all Electronic Health Records (EHRs). Potential benefits: increased efficiency and quality outcomes; improved ability to avoid adverse events; and timely access to information from your patients’ other providers. The Features of The Omaha System It is a research-based, comprehensive, standardized taxonomy or classification 01 It is designed to enhance practice, documentation, and information management It is intended for use across the continuum of care for individuals, families, and communities 02 03 It provides a structure to document client needs and strengths, describe multidisciplinary practitioner interventions, and measure client outcomes. It supports quality improvement, critical thinking, and communication. 04 The Omaha System Consists of three relational, reliable, and valid components designed to be used together: Problem Classification Scheme (client assessment) Intervention Scheme (care plans and services) Problem Rating Scale for Outcomes (client change/evaluation) Problem Rating Scale for Outcomes Intervention Scheme Problem Classification Scheme Problem Rating Scale for Outcomes 1-Problem Classification Scheme ◦ It provides a structure, terms, and system of cues and clues for a standardized assessment of individuals, families, and communities. ◦ It helps practitioners collect, sort, document, classify, analyze, retrieve, and communicate health-related needs and strengths. ◦ It is a comprehensive, orderly, non-exhaustive, mutually exclusive taxonomy or hierarchy. ◦ The Problem Classification Scheme consists of four levels of abstraction: Four domains 42 client problems Problem modifiers Signs and symptoms Level 1: Four domains Environmental: 4 problems Psychosocial: 12 problems Physiological: 18 problems Health Related Behaviors: 8 problems Domains and Problems of the Problem Classification Scheme Environmental Domain: Material resources and physical surroundings both inside and outside the living area, neighborhood, and broader community (4 problems). Income Sanitation Residence Neighborhood/workplace safety Domains and Problems of the Problem Classification Scheme Psychosocial Domain: Patterns of behavior, emotion, communication, relationships, and development (12 problems). Communication with community resources Social contact Role change Interpersonal relationship Spirituality Grief Mental health Sexuality Caretaking/parenting Neglect Abuse Growth and development Domains and Problems of the Problem Classification Scheme Physiological Domain: Functions and processes that maintain life (18 problems). Hearing Vision Speech and language Oral health Cognition Pain Consciousness Skin Neuro-musculo-skeletal function Respiration Circulation Digestion-hydration Bowel function Urinary function Reproductive function Pregnancy Postpartum Communicable/infectious condition Domains and Problems of the Problem Classification Scheme Health-related Behaviors Domain: Patterns of activity that maintain or promote wellness, promote recovery, and decrease the risk of disease (8 problems). Nutrition Sleep and rest patterns Physical activity Personal care Substance use Family planning Health care supervision Medication regimen Level 2: 42 client problems Level 3: Problem modifiers -health promotion, potential, and actual -individual, family, and community. (whose problem?) Level 4: Signs and symptoms (describe actual problems) 2-Intervention Scheme ◦ designed to describe and communicate multidisciplinary practice, practice that is intended to prevent illness, improve or restore health, decrease deterioration, and/or provide comfort before death. ◦ describes health-related care plans and services for individuals, families, and communities. Level 1: Categories Level 2: Targets Level 3: Client-specific information Level 1: Categories Categories: ◦ Teaching, Guidance, and Counseling: Activities designed to provide information and materials, encourage action and responsibility for self-care and coping, and assist the individual/family/community to make decisions and solve problems. ◦ Treatments and Procedures: Technical activities such as wound care, specimen collection, resistive exercises, and medication prescriptions that are designed to prevent, decrease, or alleviate signs and symptoms of the individual/family/community. ◦ Case Management: Activities such as coordination, advocacy, and referral that facilitate service delivery, improve communication among health and human service providers, promote assertiveness, and guide the individual/family/community toward use of appropriate resources. ◦ Surveillance: Activities such as detection, measurement, critical analysis, and monitoring intended to identify the individual/family/community's status in relation to a given condition or phenomenon. Level 2: Target 3- The Problem Rating Scale for Outcomes ◦ The Problem Rating Scale for Outcomes is a method to evaluate client progress throughout the period of service. ◦ It is three five-point, Likert-type scales ◦ It provides to measure severity for the concepts of Knowledge, Behavior, and Status 3- The Problem Rating Scale for Outcomes 3- The Problem Rating Scale for Outcomes When is it used? Admission Interim Discharge Knowledge What client knows? The aim of using the Problem Rating Scale: assessing a client's needs, determining priority interventions assessing any changes in client care Behavior What the client does? Status How the client is? Example: Problem: Respiration Modifiers: Individuals and Actual Sign/symptom: Abnormal breath sounds Concepts 1 2 3 4 5 Knowledge Doesn’t know about breathing exercises Willing to learn about breathing exercises Describes some steps of breathing exercises Describes steps of breathing exercises Superior knowledge Behavior Unwilling to use inhalers Not using but willing to learn Uses inhalers but inconsistent technique Sometimes uses inhaler with reasonable technique Uses inhaler as recommended Status Respiration rate above 40 per minute Shortness of breath, cannot climb stairs A few crackles throughout lungs Short breath in moderate exercise, lungs clear No shortness, normal lungs sounds REFERENCES ◦ Martin, K. S. (2005). The Omaha system: A key to practice. Documentation, and information management ( 2nd ed.). Omaha Nebraska: Health Connection Press. ◦ The Omaha System. https://www.omahasystem.org/ Thank you for your attention