EN ISO 18104:2014
(Main)Health informatics - Categorial structures for representation of nursing diagnoses and nursing actions in terminological systems (ISO 18104:2014)
Health informatics - Categorial structures for representation of nursing diagnoses and nursing actions in terminological systems (ISO 18104:2014)
ISO 18104:2014 specifies the characteristics of two categorial structures, with the overall aim of supporting interoperability in the exchange of meaningful information between information systems in respect of nursing diagnoses and nursing actions. Categorial structures for nursing diagnoses and nursing actions support interoperability by providing common frameworks with which to analyse the features of different terminologies, including those of other healthcare disciplines, and to establish the nature of the relationship between them, develop terminologies for representing nursing diagnoses and nursing actions, develop terminologies that are able to be related to each other, and establish relationships between terminology models, information models and ontologies in the nursing domain.
It is applicable to the following user groups: developers of terminologies that include nursing diagnosis and nursing action concepts; developers of categorial structures and terminologies for other healthcare domains, to support clarification of any relationship to or overlap with nursing concepts; developers of models for health information management systems such as electronic health records and decision support systems, to describe the expected content of terminological value domains for particular attributes and data elements in the information models; developers of information systems that require an explicit system of concepts for internal organization, data warehouse management or middleware services; developers of software for natural language processing, to facilitate harmonization of their output with coding systems.
It is not intended for use by clinical nurses without health informatics expertise. However, it provides an introduction to categorial structures to assist those without health informatics expertise to contribute to its development, review, implementation and evaluation.
Topics considered outside the scope of ISO 18104:2014 include complete categorial structures that would cover all the potential details that could appear in expressions of nursing diagnoses and nursing actions, a detailed terminology of nursing diagnoses or nursing actions, a "state model" for diagnoses or actions ? for example, provisional diagnosis or absent diagnosis, planned action or action not to be done ? diagnoses made and actions undertaken by nurses working in other professional roles, and knowledge relationships such as causal relationships between concepts.
Medizinische Informatik - Strukturen zur Darstellung von Pflegediagnosen und Pflegeaktionen in terminologischen Systemen (ISO 18104:2014)
Informatique de santé - Structures catégoriques pour la représentation des diagnostics de soins et des actions de soins dans les systèmes terminologiques (ISO 18104:2014)
L'ISO 18104:2014 spécifie les caractères de deux structures catégorielles, l'objectif général étant de permettre l'interopérabilité dans l'échange d'informations significatives entre les systèmes d'information en ce qui concerne les diagnostics infirmiers et les actions infirmières. Les structures catégorielles relatives aux diagnostics infirmiers et aux actions infirmières permettent l'interopérabilité en proposant des cadres communs avec lesquels
a) analyser les caractéristiques des différentes terminologies, y compris celles des autres disciplines du domaine des soins de santé, et établir la nature de la relation qui les unit[3]?[8],
b) élaborer des terminologies permettant de représenter les diagnostics infirmiers et les actions infirmières[9]?[12],
c) élaborer des terminologies à même d'être liées les unes aux autres[3] [8] [13] et
d) établir les relations entre les modèles de terminologie, les modèles d'information et les ontologies dans le domaine infirmier[14]?[16].
Zdravstvena informatika - Kategorijske strukture za predstavitev diagnoz in postopkov bolniške nege v terminoloških sistemih (ISO 18104:2014)
Ta mednarodni standard določa lastnosti dveh kategorijskih struktur s splošnim namenom podpore interoperabilnosti pri izmenjavi pomembnih informacij med informacijskimi sistemi, kar zadeva diagnoze in postopke bolniške nege. Kategorijske strukture za diagnoze in postopke bolniške nege podpirajo interoperabilnost z zagotavljanjem skupnih okvirjev za
a) analizo funkcij različnih terminologij, vključno s tistimi z drugih področij zdravstva, in ugotovitev narave razmerja med njimi, [3]–[8]
b) razvoj terminologij za predstavljanje diagnoz in postopkov bolniške nege,[9]–[12]
c) razvoj terminologij, ki bodo medsebojno povezane,[3] [8] [13] in
d) ugotovitev razmerij med terminološkimi modeli, informacijskimi modeli in ontologijami v bolniški domeni.[14]–[16]
Obstajajo začetni dokazi, da je mogoče kategorijske strukture uporabiti kot okvir za analizo bolniške nege[17] in razvoj vsebin, povezanih z bolniško nego, za sisteme elektronskih zapisov.[18] [19]
Ta mednarodni standard lahko uporabljajo naslednje skupine uporabnikov:
– razvijalci terminologij, ki vključujejo pojme, povezane z diagnozo in postopki bolniške nege;
– razvijalci kategorijskih struktur in terminologij za druga področja v zdravstvu v podporo pojasnitvi razmerij s pojmi, povezanimi z diagnozo in postopki bolniške nege, oziroma pojmi, ki se s temi pojmi prekrivajo;
– razvijalci modelov za sisteme upravljanja zdravstvenih podatkov, kot so sistemi elektronskih zdravstvenih zapisov in podporni sistemi za odločanje, za opisovanje pričakovane vsebine domen terminoloških vrednosti za določene atribute in podatkovne elemente v informacijskih modelih;
– razvijalci informacijskih sistemov, za katere so potrebni eksplicitni sistemi pojmov za notranjo organizacijo, upravljanje skladišč podatkov ali vmesniško programsko opremo;
– razvijalci programske opreme za naravno jezikovno obdelavo za olajšanje uskladitve rezultatov teh sistemov s kodirnimi sistemi.
Standard ni namenjen kliničnemu osebju zdravstvene nege brez strokovnega znanja o zdravstveni informatiki. Dodatek C je uvod v kategorijske strukture, s katerim si lahko posamezniki brez strokovnega znanja o zdravstveni informatiki pomagajo k boljšemu prispevku k razvoju, pregledu, uvedbi in ocenjevanju teh struktur.
OPOMBA 1: V prvi izdaji tega mednarodnega standarda je bil obseg preskušanja in pregledovanja omejen na bolniško nego, vendar pa imata obe kategorijski strukturi skupne lastnosti s splošnejšim okvirjem za klinične ugotovitve [ISO/TS 22789 in domenska kategorijska struktura za kirurške postopke (ISO 1828)[20] ter skupaj z mednarodno klasifikacijo zdravstvenih računov (ICHA) Svetovne zdravstvene organizacije].[2] Standard lahko torej deluje kot pomoč pri razvoju drugih splošnih in domenskih kategorijskih struktur v zdravstvu. Teme, ki ne spadajo na področje uporabe tega mednarodnega standarda, vključujejo:
– popolne kategorijske strukture, ki zajemajo vse morebitne podrobnosti, ki bi se lahko pojavile v izrazih za diagnoze in postopke bolniške nege,
– podrobna terminologija za diagnoze in postopke bolniške nege,
– „model stanja“ za diagnoze in postopke, npr. začasna diagnoza ali odsotnost diagnoze, načrtovani postopek ali odsvetovani postopek, glejte Dodatek A,
– podane diagnoze in opravljeni postopki, ki jih naredi osebje zdravstvene nege drugega strokovnega profila, glejte Dodatek B, in
– poznavanje razmerij, kot je vzročno razmerje med pojmi, glejte Dodatek B.
OPOMBA 2: V glavnem delu tega mednarodnega standarda, kjer so uporabljeni izrazi, kot so diagnoze in postopki bolniške nege, se ti nanašajo na predstavitev teh pojmov v elektronskih sistemih, ne na strokovno dejavnost postavljanja diagnoze ali izvedbe postopkov.
General Information
Relations
Standards Content (Sample)
SLOVENSKI STANDARD
01-julij-2014
1DGRPHãþD
SIST EN ISO 18104:2004
Zdravstvena informatika - Kategorijske strukture za predstavitev diagnoz in
postopkov bolniške nege v terminoloških sistemih (ISO 18104:2014)
Health informatics - Categorical structures for representation of nursing diagnoses and
nursing actions in terminological systems (ISO 18104:2014)
Medizinische Informatik - Kategoriale Strukturen zur Darstellung von Pflegediagnosen
und Pflegeaktionen in terminologischen Systemen (ISO 18104:2014)
Informatique de santé - Structures catégoriques pour la représentation des diagnostics
de soins et des actions de soins dans les systèmes terminologiques (ISO 18104:2014)
Ta slovenski standard je istoveten z: EN ISO 18104:2014
ICS:
11.020 0HGLFLQVNHYHGHLQ Medical sciences and health
]GUDYVWYHQRYDUVWYHQL care facilities in general
SULSRPRþNLQDVSORãQR
35.240.80 Uporabniške rešitve IT v IT applications in health care
zdravstveni tehniki technology
2003-01.Slovenski inštitut za standardizacijo. Razmnoževanje celote ali delov tega standarda ni dovoljeno.
EUROPEAN STANDARD
EN ISO 18104
NORME EUROPÉENNE
EUROPÄISCHE NORM
February 2014
ICS 35.240.80 Supersedes EN ISO 18104:2003
English Version
Health informatics - Categorial structures for representation of
nursing diagnoses and nursing actions in terminological systems
(ISO 18104:2014)
Informatique de santé - Structures catégoriques pour la Medizinische Informatik - Strukturen zur Darstellung von
représentation des diagnostics de soins et des actions de Pflegediagnosen und Pflegeaktionen in terminologischen
soins dans les systèmes terminologiques (ISO 18104:2014) Systemen (ISO 18104:2014)
This European Standard was approved by CEN on 4 January 2014.
CEN members are bound to comply with the CEN/CENELEC Internal Regulations which stipulate the conditions for giving this European
Standard the status of a national standard without any alteration. Up-to-date lists and bibliographical references concerning such national
standards may be obtained on application to the CEN-CENELEC Management Centre or to any CEN member.
This European Standard exists in three official versions (English, French, German). A version in any other language made by translation
under the responsibility of a CEN member into its own language and notified to the CEN-CENELEC Management Centre has the same
status as the official versions.
CEN members are the national standards bodies of Austria, Belgium, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia,
Finland, Former Yugoslav Republic of Macedonia, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Latvia, Lithuania,
Luxembourg, Malta, Netherlands, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, Switzerland, Turkey and United
Kingdom.
EUROPEAN COMMITTEE FOR STANDARDIZATION
COMITÉ EUROPÉEN DE NORMALISATION
EUROPÄISCHES KOMITEE FÜR NORMUNG
CEN-CENELEC Management Centre: Avenue Marnix 17, B-1000 Brussels
© 2014 CEN All rights of exploitation in any form and by any means reserved Ref. No. EN ISO 18104:2014 E
worldwide for CEN national Members.
Contents Page
Foreword .3
Foreword
This document (EN ISO 18104:2014) has been prepared by Technical Committee ISO/TC 215 “Health
informatics” in collaboration with Technical Committee CEN/TC 251 “Health informatics” the secretariat of
which is held by NEN.
This European Standard shall be given the status of a national standard, either by publication of an identical
text or by endorsement, at the latest by August 2014, and conflicting national standards shall be withdrawn at
the latest by August 2014.
Attention is drawn to the possibility that some of the elements of this document may be the subject of patent
rights. CEN [and/or CENELEC] shall not be held responsible for identifying any or all such patent rights.
This document supersedes EN ISO 18104:2003.
According to the CEN-CENELEC Internal Regulations, the national standards organizations of the following
countries are bound to implement this European Standard: Austria, Belgium, Bulgaria, Croatia, Cyprus, Czech
Republic, Denmark, Estonia, Finland, Former Yugoslav Republic of Macedonia, France, Germany, Greece,
Hungary, Iceland, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, Netherlands, Norway, Poland, Portugal,
Romania, Slovakia, Slovenia, Spain, Sweden, Switzerland, Turkey and the United Kingdom.
Endorsement notice
The text of ISO 18104:2014 has been approved by CEN as EN ISO 18104:2014 without any modification.
INTERNATIONAL ISO
STANDARD 18104
Second edition
2014-02-01
Health informatics — Categorial
structures for representation of
nursing diagnoses and nursing actions
in terminological systems
Informatique de santé — Structures catégoriques pour la
représentation des diagnostics de soins et des actions de soins dans les
systèmes terminologiques
Reference number
ISO 18104:2014(E)
©
ISO 2014
ISO 18104:2014(E)
© ISO 2014
All rights reserved. Unless otherwise specified, no part of this publication may be reproduced or utilized otherwise in any form
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ii © ISO 2014 – All rights reserved
ISO 18104:2014(E)
Contents Page
Foreword .iv
Introduction .v
1 Scope . 1
2 Normative references . 2
3 Terms and definitions . 2
3.1 General . 2
3.2 Categories of healthcare entities for nursing diagnoses . 4
3.3 List of authorized representation relations for nursing diagnoses . 5
3.4 Categories of healthcare entities for nursing actions . 6
3.5 List of authorized representation relations for nursing actions . 7
4 Categorial structures — Conformance principles . 7
5 Categorial structure for representing nursing diagnoses . 8
6 Categorial structure for representing nursing actions . 9
Annex A (informative) Summary of changes to ISO 18104:2003 .11
Annex B (informative) Nursing diagnosis and nursing actions in context .17
Annex C (informative) Guidance notes for using categorial structures .24
Bibliography .28
ISO 18104:2014(E)
Foreword
ISO (the International Organization for Standardization) is a worldwide federation of national standards
bodies (ISO member bodies). The work of preparing International Standards is normally carried out
through ISO technical committees. Each member body interested in a subject for which a technical
committee has been established has the right to be represented on that committee. International
organizations, governmental and non-governmental, in liaison with ISO, also take part in the work.
ISO collaborates closely with the International Electrotechnical Commission (IEC) on all matters of
electrotechnical standardization.
The procedures used to develop this document and those intended for its further maintenance are
described in the ISO/IEC Directives, Part 1. In particular the different approval criteria needed for the
different types of ISO documents should be noted. This document was drafted in accordance with the
editorial rules of the ISO/IEC Directives, Part 2. www.iso.org/directives
Attention is drawn to the possibility that some of the elements of this document may be the subject of
patent rights. ISO shall not be held responsible for identifying any or all such patent rights. Details of any
patent rights identified during the development of the document will be in the Introduction and/or on
the ISO list of patent declarations received. www.iso.org/patents
Any trade name used in this document is information given for the convenience of users and does not
constitute an endorsement.
For an explanation on the meaning of ISO specific terms and expressions related to conformity
assessment, as well as information about ISO’s adherence to the WTO principles in the Technical
Barriers to Trade (TBT) see the following URL: Foreword - Supplementary information
The committee responsible for this document is ISO/TC 215, Health informatics.
This second edition cancels and replaces the first edition (ISO 18104:2003), which has been technically
revised. For the history of the revision and a summary of the changes, see the Introduction and Annex A.
iv © ISO 2014 – All rights reserved
ISO 18104:2014(E)
Introduction
Development of terminological systems (also referred to as terminologies) to support nursing has been
motivated by multiple factors including the need to
— describe nursing in order to educate and inform students and others,
— represent nursing concepts in electronic systems and communications, including systems that
support multiprofessional team communications and personal health records, and
— analyse data about the nursing contribution to patient care and outcomes — for quality improvement,
research, management, reimbursement, policy and other purposes.
Multiple terminologies exist to support representation of concepts for healthcare purposes; some of
these are relevant to the nursing domain. In the context of health informatics, there is a clear requirement
for both domain coverage and for interoperability among computer-processable terminological systems
that support nursing. Nursing terminologies, or those parts of healthcare-related terminologies that are
relevant to nursing, include concept representations for nursing diagnoses and nursing actions.
A nursing diagnosis is a label assigned to an assessment finding, event, situation or other health issue
to indicate that it is considered to be noteworthy by the nurse and, where possible, the subject of care.
Nursing actions are acts performed by or under the direction of a nurse, with the intention of directly
or indirectly improving or maintaining the health of a person, group or population, the precise scope of
nursing actions being delineated in each jurisdiction. These concepts and the scope of nursing practice
are further elaborated in Annex B.
[1]
The first edition of this International Standard focused on the conceptual structures that are the
basis of nursing terminologies in order to support interoperability. A major purpose was “to establish
a nursing reference terminology model consistent with the goals and objectives of other specific health
terminology models in order to provide a more unified reference health model”. This purpose is still
relevant to this revision of the standard, to support interdisciplinary communication, for example,
where single, shared records are used, including records held by patients.
Following ISO rules, a review of ISO 18104:2003 was undertaken during 2008/09; ISO national
member bodies, nursing organisations, industry representatives and experts provided comment. In
addition to evaluation of the purpose, target groups, definitions and provisions of the standard, the
review considered the implications of relevant International Standards published since 2003. The main
findings/recommendations of the review were as follows.
a) The standard was being used in at least 11 member countries and by several international
terminology development organizations.
b) Any revision should be based on a clearly articulated value proposition supported by evidence from
the review. Published
...
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