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Terminology
Systems
Standardized Terminology
 Also called “Controlled Terminology”
Structured and controlled languages
developed and approved by an
authoritative body
 Healthcare terminology standards
designed to enable and support
interoperability and information
sharing Essential to the widespread
implementation of EHRs
How to convey important Data
and Information to others?
 The communication must be
understood by the listener and be
interpreted as having meaning.

 This
is best accomplished by using
Standard communication
formats and terminologies
Why is there a need to standardize
Nursing Terminologies?

 The birth of EHR


 Incorporation of descriptions of
nursing care into electronic
health records in a manner that
is proportionate with it’s
importance to patient’s welfare
The benefits of using standardized
nursing terminologies

 Better communication among


nurses and other healthcare
providers
 Increased visibility of nursing
interventions
 Improved patient care
The benefits of using standardized
nursing terminologies

 Enhanced data collection to


evaluate nursing care outcomes
 Greater adherence to standards
of care
 Facilitation of assessment of
nursing competency
The International Standardization
Organization (ISO)
 An International Standard (ISO
18104:2003) covering reference
terminology models for nursing
diagnoses and nursing actions

 It’s development was intended to “be


consistent with the goals and objectives
of other specific health terminology
models in order to provide a more
unified reference health model.”
American Nurses Association
(ANA)
 operates a process of de jure
standardization through its
Committee For Nursing Practice
Information Infrastructure
Standardized Nursing Terminologies

 ABC Codes (Alternative Billing


Codes)
 CCC (Clinical Care Classification)
 NMDS (Nursing Minimum Data Set)
 NANDA (North American Nursing
Diagnosis Association)
 NIC (Nursing Intervention
Classification)
 NOC (Nursing Outcomes
Classification)
Standardized Nursing Terminologies

 Omaha System
 PNDS (Peri-operative Nursing Data
Set)
 ICNP (International Classification
of Nursing Practice)
 LOINC (Logical Observation
Identifiers Names & Codes)
 SNOMED (Systematized
Nomenclature of Medicine)
Standardized Nursing Terminologies
ABC (Alternative Billing Codes)
Code
• Mechanism for coding integrative health
interventions by clinician for
administrative billing and insurance
claims.
• provide a more detailed description of
health care services to assure appropriate
reimbursement.
Standardized Nursing Terminologies
ABC (Alternative Billing Codes)
Code
• Each ABC code consists of a set of five
alphabetic characters that are used to
identify services.
• These five characters are organized in a
hierarchical structure which groups similar
products, remedies, and supplies together.
Standardized Nursing Terminologies
ABC (Alternative Billing Codes)
Code
• The five character code is then
followed by a two character code that
identifies the type of practitioner who
provided the service reflected in the
code.
• The ABC code is recognized by the
American Nurses Association
(ANA)
This is an example of an ABC code
Clinical Care Classification
(CCC) System
 is a standardized, coded nursing
terminology that identifies the
discrete elements of nursing practice.
 It provides a unique framework and
coding structure.
 Used for documenting the plan of
care; following the nursing process in
all health care settings.[1]
Clinical Care Classification
(CCC) System
 They are used to code and classify the
six steps/ standards of the ANA
Nursing Process:
 Assessment,
 Diagnosis,
 Outcome Identification (CCC
Expected Outcomes)
 Planning,
 Implementation (CCC-Interventions
Action Types), and
 Evaluation (CCC-Actual Outcomes).
Clinical Care Classification
(CCC) System
 To facilitate patient care documentation at
the point of care CCC of nursing diagnosis
and outcome:
- 182 diagnosis concepts in categories
and sub- categories;
- 3 outcome qualifiers. CCC for nursing
intervention:
- 198 concepts in categories and sub-
categories to represent interventions,
procedures, treatments, and
activities.
The NMDS
(Nursing Minimum Data Set)

Identifies
essential,
common core Intended for use
data elements to in all settings
be collected for where nurses
all patients/
clients receiving
provide care
nursing care
a. Nursing
Care

The
NMDS
includes three
categories of
elements

b. Patient . Service
c

demographics elements
c. Service elements
• Unique facility or agency number
elements
a. Nursing Care
• Unique patient health record number
• Nursing Diagnosis
• Unique number of principle registered
• Nursing Intervention
nurse
• Nursing Outcome
• Episode admission
• Intensity of Nursing care
• Discharge or termination
• Disposition of patient
• Expected payer for medical bill

b. Patient demographic elements


• Personal identification
• Date of birth
• Sex
• Race & ethnicity
• Residence
NANDA-I “North American
Nursing Diagnosis
International”

 set of nursing diagnosis helping a


practitioner to codify a clinical
judgment about an individual,
family, or community and their
response to actual or potential health
problems.
NANDA-I “North American
Nursing Diagnosis
International”
 Each nursing diagnosis actual or
potential health problem has:
description, definition, defining
characteristics (manifestations,
signs, symptoms) 13 domains, 7
axes(dimensions)
Nursing Interventions
Classification (NIC)
 is a comprehensive, research-based,
standardized classification of nursing
interventions.
 It classifies interventions, both
independent and inter-dependent, and
the nursing activities required to
implement them.
 Describe interventions used in nursing
care 30 classes, 7 domains and 542
interventions
Nursing Outcomes Classification
(NOC)
 is intended to provide a measurable
way to evaluate the effect of nursing
interventions on patient progress
 Describe outcomes related to nursing
interventions 31 classes and 7
domains of outcomes Each outcome
has: definition, measurement scale,
associated indicators, supporting
references
The Omaha System
 Applications for Community Health
Nursing
 Is the oldest of the nursing
classifications and was developed in
the 1970s by Karen Martin and
colleagues for use in community health
 It was designed for nurses in
community and public health services
 It consists of three parts: problems,
interventions, and outcomes.
The Problem Classification
Scheme consists of four domains:

 Environmental
 Psychosocial
 Physiological
 Health Related
The Problem Classification
Scheme consists of four domains:
 It includes 40 problems or diagnoses.
Modifiers for the diagnoses identify
the problem as either an individual
or family problem and as either a
health promotion, potential, or
actual problem.
 There are also signs and symptoms
specific to each problem.
The Intervention Scheme is composed
of four categories:
 Health Teaching Guidance and
 Counseling Treatments and
 Procedures Case Management
 Surveillance
They include 62 targets defined as
objects of health related interventions
or activities.
The Problem Rating Scale for
Outcomes,
 a simple 5 point, ordinal scale
comprised of Knowledge, Behavior
and Status subscales.
 Each of the three concepts is rated
for degree of response.
 Ratings are done at appropriate
intervals and when the patient is
discharged from service.
Perioperative Nursing Data Set
(PNDS).
 Members of the American Operating
Room Nurses association started the
PNDS development in 1993.
 It describes perioperative nursing
diagnoses, interventions and patient
outcomes that are specific to the
perioperative environment from
preadmission until discharge using
standardized elements.
Perioperative Nursing Data
(PNDS) Set
 Provide wording and definitions for
nursing diagnoses, interventions,
and outcomes Allow collection data
in a uniform way for analyses 4
components, 75 diagnoses, 135
interventions, and 27 nurse-sensitive
patient care outcomes
International Classification for
Nursing Practice (ICNP)
 Integrated terminology for nursing
practice developed under
sponsorship of ICN (International
Council of National Nurses)
ICNP Elements:
 nursing phenomena (Nsg. Dx)
 Nursing Actions (interventions)
 Nursing outcomes that would be
useful in both paper and electronic
records.
LOINC “Logical Observation
Identifiers, Names, and Codes”

 Terminologies for laboratory and


clinical observations
 For recording a single
observation, measurement, test
result.
SNOMED CT (Systematized
Nomenclature of Medicine -- Clinical
Terms)
 is a standardized, multilingual
vocabulary of clinical terminology
that is used by physicians and other
health care providers for the
electronic exchange of clinical
health information.