SIST EN ISO 18104:2014
(Main)Health informatics - Categorical structures for representation of nursing diagnoses and nursing actions in terminological systems (ISO 18104:2014)
Health informatics - Categorical structures for representation of nursing diagnoses and nursing actions in terminological systems (ISO 18104:2014)
This International Standard 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
a) analyse the features of different terminologies, including those of other healthcare disciplines, and to establish the nature of the relationship between them,[3]–[8]
b) develop terminologies for representing nursing diagnoses and nursing actions,[9]–[12]
c) develop terminologies that are able to be related to each other,[3] [8] [13] and
d) establish relationships between terminology models, information models and ontologies in the nursing domain.[14]–[16]
There is early evidence that the categorial structures can be used as a framework for analysing nursing practice[17] and for developing nursing content of electronic record systems.[18] [19]
This International Standard 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, Annex C provides an introduction to categorial structures to assist those without health informatics expertise to contribute to its development, review, implementation and evaluation.
NOTE 1 Although the scope of testing and review of the first edition of this International Standard has been limited to nursing, the two categorial structures have features in common with the more general framework for clinical findings [ISO/TS 22789 and the domain-specific categorial structure for surgical procedures (ISO 1828)[20] a s w ell a s w ith t he W HO I CHI].[2] The standard may therefore inform development of other general and domain-specific categorial structures in healthcare. Topics considered outside the scope of this International Standard 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 — see Annex A,
— diagnoses made and actions undertaken by nurses working in other professional roles — see Annex B — and
— knowledge relationships such as causal relationships between concepts — see Annex B.
NOTE 2 Throughout the main body of this International Standard, where terms such as nursing diagnosis and nursing action are used, these refer to representation of these concepts in electronic systems, not to the professional activity of making a diagnosis or performing an action.
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)
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
SIST EN ISO 18104:2014
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
SIST EN ISO 18104:2014 en,fr,de
2003-01.Slovenski inštitut za standardizacijo. Razmnoževanje celote ali delov tega standarda ni dovoljeno.
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SIST EN ISO 18104:2014
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SIST EN ISO 18104:2014
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.
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SIST EN ISO 18104:2014
EN ISO 18104:2014 (E)
Contents Page
Foreword .3
2
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SIST EN ISO 18104:2014
EN ISO 18104:2014 (E)
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
...
SLOVENSKI STANDARD
oSIST prEN ISO 18104:2012
01-december-2012
Zdravstvena informatika - Kategorijske strukture za predstavitev diagnoz in
postopkov bolniške nege v terminoloških sistemih (ISO/DIS 18104:2012)
Health informatics - Categorical structures for representation of nursing diagnoses and
nursing actions in terminological systems (ISO/DIS 18104:2012)
Medizinische Informatik - Kategoriale Strukturen zur Darstellung von Pflegediagnosen
und Pflegeaktionen in terminologischen Systemen (ISO/DIS 18104:2012)
Informatique de santé - Structures catégoriques pour la représentation des diagnostics
de soins et des actions de soins dans les systèmes terminologiques (ISO/DIS
18104:2012)
Ta slovenski standard je istoveten z: prEN ISO 18104
ICS:
35.240.80 Uporabniške rešitve IT v IT applications in health care
zdravstveni tehniki technology
oSIST prEN ISO 18104:2012 en,fr,de
2003-01.Slovenski inštitut za standardizacijo. Razmnoževanje celote ali delov tega standarda ni dovoljeno.
---------------------- Page: 1 ----------------------
oSIST prEN ISO 18104:2012
---------------------- Page: 2 ----------------------
oSIST prEN ISO 18104:2012
EUROPEAN STANDARD
DRAFT
prEN ISO 18104
NORME EUROPÉENNE
EUROPÄISCHE NORM
August 2012
ICS 35.240.80 Will supersede EN ISO 18104:2003
English Version
Health informatics - Categorical structures for representation of
nursing diagnoses and nursing actions in terminological systems
(ISO/DIS 18104:2012)
Informatique de santé - Structures catégoriques pour la Medizinische Informatik - Kategoriale Strukturen zur
représentation des diagnostics de soins et des actions de Darstellung von Pflegediagnosen und Pflegeaktionen in
soins dans les systèmes terminologiques (ISO/DIS terminologischen Systemen (ISO/DIS 18104:2012)
18104:2012)
This draft European Standard is submitted to CEN members for parallel enquiry. It has been drawn up by the Technical Committee
CEN/TC 251.
If this draft becomes a European Standard, 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.
This draft European Standard was established by CEN 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.
Recipients of this draft are invited to submit, with their comments, notification of any relevant patent rights of which they are aware and to
provide supporting documentation.
Warning : This document is not a European Standard. It is distributed for review and comments. It is subject to change without notice and
shall not be referred to as a European Standard.
EUROPEAN COMMITTEE FOR STANDARDIZATION
COMITÉ EUROPÉEN DE NORMALISATION
EUROPÄISCHES KOMITEE FÜR NORMUNG
Management Centre: Avenue Marnix 17, B-1000 Brussels
© 2012 CEN All rights of exploitation in any form and by any means reserved Ref. No. prEN ISO 18104:2012: E
worldwide for CEN national Members.
---------------------- Page: 3 ----------------------
oSIST prEN ISO 18104:2012
prEN ISO 18104:2012 (E)
Contents Page
Foreword .3
2
---------------------- Page: 4 ----------------------
oSIST prEN ISO 18104:2012
prEN ISO 18104:2012 (E)
Foreword
This document (prEN ISO 18104:2012) 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 document is currently submitted to the parallel Enquiry.
This document will supersede EN ISO 18104:2003.
Endorsement notice
The text of ISO/DIS 18104:2012 has been approved by CEN as a prEN ISO 18104:2012 without any
modification.
3
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oSIST prEN ISO 18104:2012
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oSIST prEN ISO 18104:2012
DRAFT INTERNATIONAL STANDARD ISO/DIS 18104
ISO/TC 215 Secretariat: ANSI
Voting begins on Voting terminates on
2012-08-23 2013-01-23
INTERNATIONAL ORGANIZATION FOR STANDARDIZATION МЕЖДУНАРОДНАЯ ОРГАНИЗАЦИЯ ПО СТАНДАРТИЗАЦИИ ORGANISATION INTERNATIONALE DE NORMALISATION
Health informatics — Categorical s
...
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