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Omaha System, palliative care, standardized terminology, transitional care



  1. Holland, Diane E. PhD, RN
  2. Vanderboom, Catherine E. PhD, RN
  3. Dose, Ann Marie PhD, RN
  4. Delgado, Adriana M. CCRP
  5. Austin, Christine M. RN, CCRP
  6. Ingram, Cory J. MD
  7. Wild, Ellen M. RN, CHPN
  8. Monsen, Karen A. PhD, RN, FAAN


We used a standardized terminology to describe patient problems and the nursing care provided in a pilot study of a transitional palliative care intervention with patients and caregivers. Narrative phrases of a nurse's documentation were mapped to the Omaha System (problem, intervention, and target). Over the course of the intervention, 109 notes (1473 phrases) were documented for 9 adults discharged home (mean age, 68 years; mean number of morbid conditions, 7.1; mean number of medications, 15.4). Thirty-one of the 42 Omaha System problems were identified; the average number of problems per patient was 13. Phrases were mapped to all 4 problem domains (environmental, 2.6%; health-related behaviors, 52.3%; physiological, 30.8%; and psychosocial, 14.3%). Surveillance phrases were the most frequent (72.4%); case management phrases were at 20.9%, and teaching, guidance, and counseling phrases were at 6.7%. The number of problems documented per patient correlated with the time between the first and last notes ([rho] = 0.76; P = .02) but not with the number of notes per patient ([rho] = 0.51; P = .16). These results are the first to describe nursing interventions in transitioning palliative care from hospital to home with a standardized terminology. Linking interventions to patient problems is critical for describing effective strategies in transitioning palliative care from hospital to home.