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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
 Increased visibility of nursing
 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
 operates a process of de jure
standardization through its
Committee For Nursing Practice
Information Infrastructure
Standardized Nursing Terminologies

 ABC Codes (Alternative Billing

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

 Omaha System
 PNDS (Peri-operative Nursing Data
 ICNP (International Classification
of Nursing Practice)
 LOINC (Logical Observation
Identifiers Names & Codes)
 SNOMED (Systematized
Nomenclature of Medicine)
Standardized Nursing Terminologies
ABC (Alternative Billing Codes)
• Mechanism for coding integrative health
interventions by clinician for
administrative billing and insurance
• provide a more detailed description of
health care services to assure appropriate
Standardized Nursing Terminologies
ABC (Alternative Billing Codes)
• 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)
• 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
• The ABC code is recognized by the
American Nurses Association
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
- 198 concepts in categories and sub-
categories to represent interventions,
procedures, treatments, and
(Nursing Minimum Data Set)

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

includes three
categories of

b. Patient . Service

demographics elements
c. Service elements
• Unique facility or agency number
a. Nursing Care
• Unique patient health record number
• Nursing Diagnosis
• Unique number of principle registered
• Nursing Intervention
• 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

 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
NANDA-I “North American
Nursing Diagnosis
 Each nursing diagnosis actual or
potential health problem has:
description, definition, defining
characteristics (manifestations,
signs, symptoms) 13 domains, 7
Nursing Interventions
Classification (NIC)
 is a comprehensive, research-based,
standardized classification of nursing
 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
Nursing Outcomes Classification
 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
The Omaha System
 Applications for Community Health
 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
 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
 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
LOINC “Logical Observation
Identifiers, Names, and Codes”

 Terminologies for laboratory and

clinical observations
 For recording a single
observation, measurement, test
SNOMED CT (Systematized
Nomenclature of Medicine -- Clinical
 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.