From Unstructured to Structured Nursing Documentation for Myocardial Infarction Patients Using Clinical Practice Guidelines and SNOMED CT.

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%).