FEATURESDeveloping Structured Omaha System Goals for Use in an Electronic Health RecordO'Neill, Ann M. MSN, RN-BC; Mossing, Michael R. MS, RN; Newcome, Marci D. DNP, APRN, CNP; Miller, Kari B. DNP, RN, PHN; Monsen, Karen A. PhD, RN, FAMIA, FAANAuthor Information Author Affiliations: Bon Secours Health System, Richmond, Virginia (Ms O'Neill); Mayo Clinic, Rochester, Minnesota (Mr Mossing and Dr Newcome); and Optum, Eden Prairie, Minnesota (Dr Miller); and University of Minnesota, Minneapolis (Dr Monsen). The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Corresponding author: Marci D. Newcome, DNP, APRN, CNP, 200 First Street SW, Rochester, MN 55905 (email@example.com). Online date: November 5, 2019 CIN: Computers, Informatics, Nursing: December 2019 - Volume 37 - Issue 12 - p 655-661 doi: 10.1097/CIN.0000000000000568 Buy Metrics Abstract Use of standardized terminology has been essential for clear, concise, and accurate documentation of client assessments, care plans, and outcomes. The purpose of this study was to create standardized language goals for a case management system that used the Omaha System. A group of nursing informaticists analyzed, refined, and developed revised goals evaluated using medical vocabulary properties. A set of unique goals aligned with the Omaha System was developed with specifically designed characteristics and functionality that allowed individualization and evaluation of goal attainment. Goal statements and ratings were standardized and written to reflect goals a client could attain. The Omaha System goals served as a template for nurse case managers to use in telephonic support with clients and future development of new goals and allowed the organization the ability to generate quality metrics. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.