Classifying Perinatal Advanced Practice Data With the Omaha System

Abstract

This pilot study analyzed perinatal advanced practice registered nurse (APRN) diagnoses/client problems and interventions across sites using standardized terminology. APRN verbatim encounter logs from 8 patients in a previous study were coded by both the Omaha System and Current Procedural Terminology (CPT) codes. Previous outcomes were reduced preterm births, hospitalizations, and costs (Brooten et al., 2001). In 597 encounters (63% by telephone), 27 diagnoses and 8,077 interventions were recorded. Health Teaching, Guidance, and Counseling were 42%; Surveillance, 38%; Treatments and Procedures, 11%; and Case Management, 9%. Health Teaching, Guidance, and Counseling were most frequent in clinic (51%) and phone encounters (45%). Surveillance was 30% to 35% at each site. Treatments and Procedures occurred most frequently in home and clinic visits, whereas Case Management occurred most in clinic and phone visits. When coded with CPT, more than 80% of interventions were unlisted. Documentation using standardized terminology would facilitate the study of effective nursing interventions.