The Omaha System-final
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The Omaha System
a research-based, comprehensive classification system that promotes documentation of client care
It is a framework for integrating and sharing clinical data that has existed in the public domain since 1965
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 problemoriented approach. DeLanne Simmons, VNA of Omaha Chief Executive Officer, envisioned a computerized management information system that incorporated an integrated, valid and reliable clinical information system organized around clients who received services, not the multidisciplinary practitioners who provided services.
PURPOSE Developed to guide community health nursing practice and serve as a method for documentation of care and data management It provides a structure to document client needs and strengths, describe multidisciplinary practitioner interventions and measure client outcomes in a simple and user-friendly yet comprehensive manner
Capabilities and Characteristics
Advances the scientific practice of nursing Offers capabilities to quantify community health nursing Is practical for general community health application Is congruent with the nursing process Minimizes redundancies in the client record Limits documentation time.
MAJOR CONCEPTS
Problem Classification Scheme Intervention Scheme Problem Rating Scale for Outcomes
PROBLEM-CLASSIFICATION SCHEME
Designed to identify diverse clients’ health-related concerns Consists of four levels
I. Four domains Represent priority areas of practitioner and client health-related concerns
Environmental Domain
Material resources and physical surroundings both inside and outside the living area, neighborhood, and broader community.
Income Sanitation Residence Neighborhood/workplace safety
Psychosocial Domain
Patterns of behavior, emotion, communication, relationships, and development.
Communication with community resources Spirituality Grief Mental health Sexuality Caretaking/parenting
Physiological Domain
Functions and processes that maintain life
Hearing Vision Speech and language Respiration Circulation Digestion-hydration
Health Related Behaviors Domain
Patterns of activity that maintain or promote wellness, promote recovery, and decrease the risk of disease.
Nutrition Sleep and rest patterns Physical activity Personal care Substance use Family planning
II. Concepts, referred to as client problems or areas of clients needs and strengths III. Two sets of problem modifiers Health promotion, potential and actual
Individual, family and community
IV. Clusters of signs and symptoms that describe actual problems
INTERVENTION SCHEME
Designed to address specific problems for diverse clients. the basis for planning and intervening, it enables practitioners to describe and communicate their practice including improving or restoring health, decreasing deterioration, or preventing illness.
Three levels of professional actions or activities
I. Four broad categories of interventions
Teaching, Guidance, and Counseling Treatments and Procedures Case Management Surveillance
II. Alphabetical lists of 75 targets or objects of action
anatomy/physiolog anger management behavior modification bladder care dressing change/wound care durable medical equipment education Employment end-of-life care environment medication set-up mobility/transfers nursing care nutritionist care sickness/injury care signs/symptoms-mental/emotional signs/symptoms-physical skin care social work/counseling care
III. Client-specific information generated by practitioners
Problem Rating Scale for Outcomes
Consists of three five-point, Likert-type scales for measuring the entire range of severity for the concepts of knowledge, behavior and status
Provides an evaluation framework for examining problem specific client ratings at regular or predictable times
Concept s Knowledge : Ability of the client to remember and interpret Behavior: information Observable responses, actions, or activities of the client fitting the occasion or purpose
1
2
3
4
5
No Minimal Basic Adequate Superior knowledg knowledg knowledg knowledg knowledg e e e e e
Not appropria te behavior
Rarely appropria te behavior
Inconsist ently appropria te behavior
Usually appropria te behavior
Consisten tly appropria te behavior
Status: Condition of the client in relation to objective and subjectiv e defining characteri stics
Extreme signs/ sympto ms
Severe signs/ sympto ms
Moderat e signs/ sympto ms
Minimal signs/ sympto ms
No signs/ sympto ms
a research-based, comprehensive classification system that promotes documentation of client care
It is a framework for integrating and sharing clinical data that has existed in the public domain since 1965
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 problemoriented approach. DeLanne Simmons, VNA of Omaha Chief Executive Officer, envisioned a computerized management information system that incorporated an integrated, valid and reliable clinical information system organized around clients who received services, not the multidisciplinary practitioners who provided services.
PURPOSE Developed to guide community health nursing practice and serve as a method for documentation of care and data management It provides a structure to document client needs and strengths, describe multidisciplinary practitioner interventions and measure client outcomes in a simple and user-friendly yet comprehensive manner
Capabilities and Characteristics
Advances the scientific practice of nursing Offers capabilities to quantify community health nursing Is practical for general community health application Is congruent with the nursing process Minimizes redundancies in the client record Limits documentation time.
MAJOR CONCEPTS
Problem Classification Scheme Intervention Scheme Problem Rating Scale for Outcomes
PROBLEM-CLASSIFICATION SCHEME
Designed to identify diverse clients’ health-related concerns Consists of four levels
I. Four domains Represent priority areas of practitioner and client health-related concerns
Environmental Domain
Material resources and physical surroundings both inside and outside the living area, neighborhood, and broader community.
Income Sanitation Residence Neighborhood/workplace safety
Psychosocial Domain
Patterns of behavior, emotion, communication, relationships, and development.
Communication with community resources Spirituality Grief Mental health Sexuality Caretaking/parenting
Physiological Domain
Functions and processes that maintain life
Hearing Vision Speech and language Respiration Circulation Digestion-hydration
Health Related Behaviors Domain
Patterns of activity that maintain or promote wellness, promote recovery, and decrease the risk of disease.
Nutrition Sleep and rest patterns Physical activity Personal care Substance use Family planning
II. Concepts, referred to as client problems or areas of clients needs and strengths III. Two sets of problem modifiers Health promotion, potential and actual
Individual, family and community
IV. Clusters of signs and symptoms that describe actual problems
INTERVENTION SCHEME
Designed to address specific problems for diverse clients. the basis for planning and intervening, it enables practitioners to describe and communicate their practice including improving or restoring health, decreasing deterioration, or preventing illness.
Three levels of professional actions or activities
I. Four broad categories of interventions
Teaching, Guidance, and Counseling Treatments and Procedures Case Management Surveillance
II. Alphabetical lists of 75 targets or objects of action
anatomy/physiolog anger management behavior modification bladder care dressing change/wound care durable medical equipment education Employment end-of-life care environment medication set-up mobility/transfers nursing care nutritionist care sickness/injury care signs/symptoms-mental/emotional signs/symptoms-physical skin care social work/counseling care
III. Client-specific information generated by practitioners
Problem Rating Scale for Outcomes
Consists of three five-point, Likert-type scales for measuring the entire range of severity for the concepts of knowledge, behavior and status
Provides an evaluation framework for examining problem specific client ratings at regular or predictable times
Concept s Knowledge : Ability of the client to remember and interpret Behavior: information Observable responses, actions, or activities of the client fitting the occasion or purpose
1
2
3
4
5
No Minimal Basic Adequate Superior knowledg knowledg knowledg knowledg knowledg e e e e e
Not appropria te behavior
Rarely appropria te behavior
Inconsist ently appropria te behavior
Usually appropria te behavior
Consisten tly appropria te behavior
Status: Condition of the client in relation to objective and subjectiv e defining characteri stics
Extreme signs/ sympto ms
Severe signs/ sympto ms
Moderat e signs/ sympto ms
Minimal signs/ sympto ms
No signs/ sympto ms
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