Omaha System: A useful strategy for practice and education

Background and Issues: Increasingly, public health department managers and educators need to use structured clinical documentation, measure outcomes, introduce electronic health records (EHRs), and use information technology. Description: Leaders in practice and education want to provide high quality services to the residents of their communities including vulnerable populations and those who are disadvantaged. Many are embracing the Omaha System because it exists in the public domain; was designed to enhance collection, aggregation, and analysis of clinical data; and supports clinical reasoning, quality improvement, and communication. It is integrated into SNOMED CT® and other reference terminologies being mandated for inclusion in electronic health records nationally. Lessons Learned: In 1999, administrators, managers, and staff of a state public health department became interested in the Omaha System. The public health nursing program has 15 offices and provides services to individuals, families, and communities throughout the state. Nurses assess health status, define health options, develop policies, and assure access to services for the state's residents who are demographically diverse and include many recent immigrants. Use of the Omaha System allows nurses to consistently describe, document, and evaluate their impact on client outcomes. It provides a communication framework to standardize statewide documentation, generate quantitative and qualitative data, and establish information management self-sufficiency. In 2005, educators at a college of nursing became interested in the Omaha System. Students are introduced to the Omaha System in a Level 2 course, and use it to document the impact, outcomes, and community benefit of their practice. As a result of wellness contracts in community corrections and summer camps, students have service-learning clinical experiences where they provide and document case management services. Many services are provided to vulnerable groups. The Omaha System helps promote clinical reasoning throughout the curriculum, and an understanding of the need for consistent and accurate data in all practice settings. Recommendations: Nurses employed in public health departments, nursing educators, and their non-nurse colleagues in practice and education need to become better informed about and begin to use standardized terminologies, EHRs, and information technology.