SIST EN ISO 18104:2004
(Main)Health Informatics - Integration of a reference terminology model for nursing (ISO 18104:2003)
Health Informatics - Integration of a reference terminology model for nursing (ISO 18104:2003)
The purpose of ISO 18104:2003 is 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 International Standard includes the development of reference terminology models for nursing diagnoses and nursing actions and relevant terminology and definitions for its implementation.
The potential uses for this reference terminology model are to
support the intensional definition of nursing diagnosis and nursing action concepts reflective of a broad range of roles and practice settings,
facilitate the representation of nursing diagnosis and nursing action concepts and their relationships in a manner suitable for computer processing,
provide a framework for the generation of compositional expressions from atomic concepts within a reference terminology,
facilitate the construction of nursing terminologies in a regular form which will make mapping among them easier,
facilitate the mapping among nursing diagnosis and nursing action concepts from various terminologies including those developed as interface terminologies and statistical classifications,
enable the systematic evaluation of terminologies and associated terminology models for purposes of harmonization, and
provide a language to describe the structure of nursing diagnosis and nursing action concepts in order to enable appropriate integration with other reference terminology models and with information models.
Medizinische Informatik - Integration eines Referenz-Terminologiemodells für die Pflege (ISO 18104:2003)
Informatique de santé - Intégration d'un modele de terminologie de référence pour les soins infirmiers (ISO 18104:2003)
L'ISO 18104:2003 vise à établir un modèle de terminologie de référence pour les soins infirmiers compatible avec les buts et les objectifs d'autres modèles de terminologie de santé spécifiques, dans le but de proposer un modèle de référence unifié pour le domaine de la santé. L'ISO 18104:2003 comprend l'élaboration de modèles de terminologie de référence pour les diagnostics infirmiers et les actions infirmières, ainsi qu'une terminologie pertinente et les définitions nécessaires à sa mise en application.
Les utilisations potentielles de ce modèle de terminologie de référence sont
de permettre la définition par compréhension des concepts relatifs aux diagnostics infirmiers et aux actions infirmières comme le reflet d'une grande variété de rôles et de lieux d'exercice,
de faciliter la représentation des concepts relatifs aux diagnostics infirmiers et aux actions infirmières et de leurs relations d'une manière permettant un traitement informatique,
de fournir un cadre pour la génération d'expressions compositionnelles formées à partir de concepts isolés dans une terminologie de référence,
de permettre l'élaboration de terminologies pour les soins infirmiers selon un format uniformisé facilitant les correspondances,
de faciliter les correspondances entre les concepts relatifs aux diagnostics infirmiers et aux actions infirmières issus de différentes terminologies, notamment celles mises au point comme terminologies d'interface et classifications statistiques,
de permettre l'évaluation systématique des terminologies et des modèles de terminologie associés à des fins d'harmonisation, et
de proposer un langage permettant de décrire la structure des concepts relatifs aux diagnostics infirmiers et aux actions infirmières dans le but de permettre une intégration appropriée avec d'autres modèles de terminologie de référence et à des modèles d'information.
Zdravstvena informatika – Integracija referenčnega modela terminologije za bolniško nego (ISO 18104:2003)
General Information
Relations
Standards Content (Sample)
SLOVENSKI STANDARD
SIST EN ISO 18104:2004
01-maj-2004
1DGRPHãþD
SIST ENV 14032:2003
=GUDYVWYHQDLQIRUPDWLND±,QWHJUDFLMDUHIHUHQþQHJDPRGHODWHUPLQRORJLMH]D
EROQLãNRQHJR ,62
Health Informatics - Integration of a reference terminology model for nursing (ISO
18104:2003)
Medizinische Informatik - Integration eines Referenz-Terminologiemodells für die Pflege
(ISO 18104:2003)
Informatique de santé - Intégration d'un modele de terminologie de référence pour les
soins infirmiers (ISO 18104:2003)
Ta slovenski standard je istoveten z: EN ISO 18104:2003
ICS:
35.240.80 Uporabniške rešitve IT v IT applications in health care
zdravstveni tehniki technology
SIST EN ISO 18104:2004 en
2003-01.Slovenski inštitut za standardizacijo. Razmnoževanje celote ali delov tega standarda ni dovoljeno.
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SIST EN ISO 18104:2004
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SIST EN ISO 18104:2004
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SIST EN ISO 18104:2004
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SIST EN ISO 18104:2004
INTERNATIONAL ISO
STANDARD 18104
First edition
2003-12-15
Health informatics — Integration of a
reference terminology model for nursing
Informatique de santé — Intégration d'un modèle de terminologie de
référence pour les soins infirmiers
Reference number
ISO 18104:2003(E)
©
ISO 2003
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SIST EN ISO 18104:2004
ISO 18104:2003(E)
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SIST EN ISO 18104:2004
ISO 18104:2003(E)
Contents Page
Foreword. iv
Introduction . v
1 Scope. 1
2 Normative references . 2
3 Terms and definitions. 2
4 Reference terminology model for nursing diagnoses . 3
5 Reference terminology model for nursing actions. 5
Annex A (informative) Examples of dissections of nursing diagnoses. 8
Annex B (informative) Examples of dissections of nursing actions. 13
Annex C (informative) Examples of dissections of diagnoses and actions from disciplines other
than nursing . 17
Annex D (informative) Conventions used in figures of models. 21
Annex E (informative) Summary of evidence for model components . 23
Annex F (informative) Summary of issues related to reference terminology models. 25
Bibliography . 27
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SIST EN ISO 18104:2004
ISO 18104:2003(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.
International Standards are drafted in accordance with the rules given in the ISO/IEC Directives, Part 2.
The main task of technical committees is to prepare International Standards. Draft International Standards
adopted by the technical committees are circulated to the member bodies for voting. Publication as an
International Standard requires approval by at least 75 % of the member bodies casting a vote.
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.
ISO 18104 was prepared by Technical Committee ISO/TC 215, Health informatics. Through a work item
proposal initiated by the International Council of Nurses and the Nursing Informatics Special Interest Group of
the International Medical Informatics Association, the work related to this International Standard takes forward,
under the Vienna Agreement, the efforts initiated in ENV 14032, Health Informatics — System of concepts to
support nursing.
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SIST EN ISO 18104:2004
ISO 18104:2003(E)
Introduction
Terminology development in nursing has been motivated by multiple factors including
• implementation of computer-based systems in clinical settings,
• quest for reimbursement for nursing services delivered,
• documentation of nursing contributions to patient care outcomes,
• teaching students, and
• enhancing the body of nursing knowledge.
Nursing terminologies, in either paper-based or computer-based form, have been designed as enumerated
classifications and implemented both as interface terminologies at the point of care and as administrative
terminologies to examine nursing data across settings. At the present time, many standardized terminologies
exist and no single standardized terminology is complete for the domain in terms of breadth or granularity.
Moreover, there is currently no concept-oriented terminology that integrates the domain concepts of nursing in
a manner suitable for computer processing.
In recent years, however, significant advances have been made toward the development of concept-oriented
reference terminologies that support the domain concepts of nursing. Among the remaining major challenges
are the development of a reference terminology model that supports the representation of nursing concepts
and the integration of the reference terminology model with other models for the health-care domain [1]. A
number of efforts have focused on addressing these challenges. Prominent among these is the work within
the European Standardization Committee (CEN TC 251) that brought together the efforts of the International
Classification for Nursing Practice (ICNP ) Programme, Telenurse ID, and other European efforts (e.g.,
nursing activities within the Galen programme) into a Prestandard — ENV 14032 [2], [3], [4], [5], [6]. Also of
relevance to this International Standard are activities related to the International Medical Informatics
Association Nursing Informatics Special Interest Group, Nursing Terminology Summits, Systematized
Nomenclature of Medicine (SNOMED ) Convergent Terminology Group for Nursing, Health Level 7, and
Clinical Logical Observation Identifiers, Names, and Codes (LOINC) [3], [7], [8], [9].
In contrast to the CEN Prestandard that broadly addressed categorial structures for nursing diagnoses and
nursing actions, this International Standard focuses specifically on the conceptual structures that are
represented in a reference terminology model rather than in other types of information models. Moreover,
toward the goal of integration with other health-care models, the reference terminology models for nursing
diagnoses and nursing actions in this International Standard reflect attempts at harmonisation with evolving
terminology and information model standards outside the domain of nursing.
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SIST EN ISO 18104:2004
INTERNATIONAL STANDARD ISO 18104:2003(E)
Health informatics — Integration of a reference terminology
model for nursing
1 Scope
1.1 Main purpose
The purpose of this International Standard is 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 International Standard includes the development of reference terminology
models for nursing diagnoses and nursing actions and relevant terminology and definitions for its
implementation.
The potential uses for this reference terminology model are to
• support the intensional definition of nursing diagnosis and nursing action concepts reflective of a broad
range of roles and practice settings,
• facilitate the representation of nursing diagnosis and nursing action concepts and their relationships in a
manner suitable for computer processing,
• provide a framework for the generation of compositional expressions from atomic concepts within a
reference terminology,
• facilitate the construction of nursing terminologies in a regular form which will make mapping among them
easier,
• facilitate the mapping among nursing diagnosis and nursing action concepts from various terminologies
including those developed as interface terminologies and statistical classifications,
• enable the systematic evaluation of terminologies and associated terminology models for purposes of
harmonization, and
• provide a language to describe the structure of nursing diagnosis and nursing action concepts in order to
enable appropriate integration with other reference terminology models and with information models.
1.2 Target groups
The target groups for this International Standard are
• developers of coding systems and terminologies that include nursing diagnosis and nursing action
concepts, to assist in the development, refinement, and maintenance of a particular terminology, as well
as for comparisons among different systems,
• developers of reference terminology models for other health-care domains, to explicate the relationships
and overlap with nursing concepts,
• information modellers, knowledge engineers, and standards developers building 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 and middleware services,
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• developers of software for natural language processing, to facilitate harmonisation of their output with
coding systems, and
• developers of mark-up standards for representation of health-care documents.
1.3 Topics considered outside scope
Topics considered outside the scope of this International Standard include
• a comprehensive categorial structure for nursing diagnoses and nursing interventions,
• a detailed classification, nomenclature, or reference terminology of nursing diagnoses or nursing actions,
• descriptors and guidelines to represent contextual information for the recording of information within an
electronic health record,
• an exhaustive list of all the potential details that could appear in expressions of nursing diagnoses and
nursing actions,
• an exhaustive thesaurus with the complete list of descriptors to be used to describe nursing diagnoses
and nursing actions,
• relationships among health professionals, and
• communication of nursing diagnosis and nursing action concepts between electronic health records.
2 Normative references
The following referenced documents are indispensable for the application of this document. For dated
references, only the edition cited applies. For undated references, the latest edition of the referenced
document (including any amendments) applies.
ISO/TS 17117:2002, Health informatics — Controlled health terminology — Structure and high-level indicators
ENV 12264:1997, Medical informatics — Categorial structures of systems of concepts — Model for
representation of semantics
ENV 14032:2001, Health Informatics — System of concepts to support nursing
3 Terms and definitions
For the purposes of this International Standard, the following terms and definitions apply. Only key terms and
definitions are provided in this section. Additional background terms and definitions from
ISO 1087-1:2000 [27] are provided in Annex A. Definitions for the specific reference terminology model
components are provided in Clauses 4 and 5.
3.1
domain concept model
set of formal categories, semantic links and sanctions describing potential characteristics for representing
concepts in a domain
[ISO 17115]
3.2
reference terminology model
domain concept model (3.1) that is optimised for terminology management
3.3
dissection
systematic representation of a phrase according to a predefined domain concept model
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4 Reference terminology model for nursing diagnoses
4.1 General
For the purposes of this International Standard, a nursing diagnosis is considered either as a
1) 2)
<> on a <> or as a <> on a particular (e.g. ability,
knowledge) of a <> (see ENV 14032). A graphical representation of the reference terminology model
for nursing diagnoses is shown in Figure 1. A descriptor for <> and a descriptor for <>
are mandatory for the intensional definition of a nursing diagnosis. In some special instances, a single
descriptor (e.g., anxiety) can serve the role of both <> and <>. In contrast to ENV 14032,
no base category is specified; the decision is at the discretion of the terminology developer and/or
implementer. Annex C includes examples of three styles of dissection: <> as the base category,
<> as the base category, and a single descriptor for <> and <>. Descriptors
for other semantic domains, semantic categories, and qualifiers described in 4.4 to 4.6 should be used as
necessary to support the intensional definition of a specific nursing diagnosis.
Figure 1 — Reference terminology model for nursing diagnoses
4.2 Focus
4.2.1 Definition
Focus is defined as an area of attention [10]. <> may be qualified by timing.
4.2.2 Examples of semantic categories
Semantic categories for the domain of <> include, but are not limited to: , ,
, and . In the case of , and , the
descriptor of <> is pre-coordinated with the descriptor of <>, e.g., anxiety. Categories of
<> may also take the role of <> in the reference terminology model for nursing actions.
1) Semantic domains are considered as abstract classes of UML that are used as organising categories to simplify the
models. Semantic domains are italicised in the diagrams and their labels are enclosed in double angle brackets << >>
throughout the document.
2) Semantic categories are considered as instantiable classes in UML and their labels are in plain font in the diagrams.
They are enclosed in angle brackets < > throughout the document.
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4.3 Judgement
4.3.1 Definition
<> is an opinion or discernment related to a <> or (modified from
ENV 14032). A descriptor for <> is mandatory for nursing diagnoses. <> may be
qualified by degree, potentiality, timing, and acuity. Descriptors of degree (scale of gradations) include, but are
not limited to: very, mild, and extreme. Descriptors of timing (a point or period in time) include, but are not
limited to: during a procedure, perinatal, and postoperative. Descriptors of acuity (duration) include, but are
not limited to: acute and chronic. Descriptors of potentiality (possibility) include, but are not limited to: risk for,
actual, possibility of, and potential.
4.3.2 Examples of semantic categories
Semantic categories in the judgement domain include, but are not limited to: , ,
, and . In the case of ,
and , the descriptor of <> is pre-coordinated with the descriptor of <>,
e.g. anxiety.
4.4 Dimension
4.4.1 Definition
is a quality possessed by an or which provides a perspective on, but is not
limited to: , , other semantic categories taking the role of focus, and nursing diagnosis
(see ENV 14032). may also take the role of <> in the reference terminology model for
nursing actions.
4.4.2 Examples of descriptors for the semantic category
Example descriptors include, but are not limited to: knowledge, motivation, and ability.
4.5 Subject of information
4.5.1 Definition
<> is an entity to which a diagnosis refers, also known as the “bearer” in ENV 14032.
A descriptor for <> should be used as necessary to disambiguate similar rubrics (e.g.,
ineffective family coping vs. ineffective individual coping) in a terminology.
4.5.2 Examples of semantic categories
Semantic categories in the <> domain include, but are not limited to: ,
, and .
4.6 Site
4.6.1 Definition
A physical structure that further specifies the position of a <> or a <> (see ENV 14032).
4.6.2 Examples of semantic categories
Semantic categories include, but are not limited to: , (e.g., a wound),
and .
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4.7 Semantic links
All semantic links, with the exception of the reciprocal of is applied to (IS JUDGED BY), were included in
ENV 14032. Examples of use of the semantic links are provided in Annex C.
has acuity
semantic link used to represent associative relations between the qualifier of acuity and <>
has degree
semantic link used to represent associative relations between the qualifier of degree and <>
has potentiality
semantic link used to represent associative relations between the qualifier of potentiality and <>
has subject of information
semantic link used to represent associative relations between <> and <>
has site
semantic link used to represent associative relations between <> and <>
has timing
semantic link used to represent associative relations between the qualifier of timing and <>,
<>, and .
is applied to (IS JUDGED BY)
semantic links used to represent associative relations between <> and <> and
is perspective on
semantic link used to represent associative relations between <> and
5 Reference terminology model for nursing actions
5.1 General
For the purposes of this International Standard, a nursing action is considered an intentional act applied to a
<> through an . A graphical representation of the reference terminology model for nursing
actions is shown in Figure 2. A descriptor for and a descriptor for <> are mandatory for the
intensional definition of a nursing action. Annex D includes examples of dissections. Descriptors for other
semantic domains, semantic categories, and qualifiers described in 5.4 to 5.7 should be used as necessary to
support the intensional definition of specific nursing actions within a particular terminology.
5.2 Action
5.2.1 Definition
An is the process by which an intentional service is applied to a recipient of care [11], [12]. Actions
are frequently represented in compositional expressions as verbs or verb phrases. All nursing actions have an
. may be qualified by timing.
5.2.2 Examples of descriptors for the semantic category
Examples of descriptors for include, but are not limted to: observing, teaching, preventing, and
feeding. In some terminologies (e.g., ICNP , Home Health Care Classification) [13], [14] instances of nursing
are classified into broad categories such as assessing, teaching, performing, caring, and managing.
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Figure 2 — Reference terminology model for nursing actions
5.3 Target
5.3.1 Definition
<> is the entity that is affected by the nursing action or that provides the content of the nursing
action [11], [13], [15]. All nursing actions have a <>.
5.3.2 Examples of semantic categories
Semantic categories in the <> domain include, but are not limited to: , ,
, , , , , , , ,
and the categories that have the role of <> in nursing diagnoses (see 4.2). Nursing diagnosis can also
be a <>.
5.4 Means
5.4.1 Definition
<> is the entity used in performing a nursing action [13].
5.4.2 Examples of semantic categories
Semantic categories include, but are not limited to: , and .
5.5 Route
5.5.1 Definition
is a path through which something may pass (see ENV 14032).
5.5.2 Examples of descriptors for the semantic category
Example descriptors for include, but are not limited to: oral route, subcutaneous, and epidural.
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5.6 Site
5.6.1 Definition
<> is a physical structure that further specifies the position of a <> or a <> (see
ENV 14032).
5.6.2 Examples of semantic categories
Semantic categories include, but are not limited to: , (e.g. a wound),
and .
5.7 Recipient of care
5.7.1 Definition
The <> is the person, family, group, or other aggregate to whom the action is delivered.
<> should be used when necessary to avoid ambiguities in a set of descriptors within a
terminology.
5.7.2 Examples of semantic categories
Examples of semantic categories include, but are not limited to: , , and
environment>.
5.8 Semantic links
acts on
semantic link used to represent associative relations between and <>
has recipient of care
semantic link used to represent associative relations between and <>
has means
semantic link used to represent associative relations between and <>
has route
semantic link used to represent associative relations between and
has site
semantic link used to represent associative relations between and <>
has timing
semantic link used to represent associative relations between the qualifier of timing and <>,
<>, and
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Annex A
(informative)
Examples of dissections of nursing diagnoses
A.1 General
This Annex provides examples of dissections of nursing diagnoses. The sources of the diagnoses are the
ENV 14032 informative Annex (denoted by *) and selected terms from standardized terminologies that include
nursing diagnoses including the North American Nursing Diagnosis Association Taxonomy 1 and Taxonomy 2,
the Home Health Care Classification, and the Omaha System. The following dissections are constructed
under the assumption that the default value for potentiality is “actual” and that the default value for <
of information>> is “client”. The reference terminology model proposed in this International Standard specifies
that either <> or <> can serve as the base category for concept definition. Thus, in the
first set of examples, <> is used as the base category. In the second set, <> is used as
the base category. The third set of examples is nursing diagnoses that contain both <> and
<> in a simple term.
A.2 Examples with Judgement as base category
A.2.1
decreased parenting ability
decrease
has potentiality actual
is applied to ability
is perspective on parenting
has subject of information client
A.2.2
reduction of ability to bathe oneself*
reduction
has potentiality actual
is applied to ability
is perspective on bathing oneself
has subject of information client
A.2.3
reduced ability to write*
reduction
has potentiality actual
is applied to ability
is perspective on writing
has subject of information client
A.2.4
activities of daily living alteration
alteration
has potentiality actual
is applied to activities of daily living
has subject of information client
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A.2.5
inability to toilet
inadequacy
has potentiality actual
is applied to ability
is perspective on toileting
has subject of information client
NOTE This example makes explicit the fact that “inability” is a nominalisation of “unable”, i.e. that the “ability” is
“inadequate”.
A.2.6
alteration in sexuality patterns*
alteration
has potentiality actual
is applied to sexuality pattern
has subject of information client
A.2.7
alteration in gastrointestinal tissue perfusion*
alteration
has potentiality actual
is applied to perfusion
has site gastrointestinal tissue
has subject of information client
A.2.8
reduction in ability to concentrate*
reduction
has potentiality actual
is applied to ability
is perspective on concentrating
has subject of information client
A.2.9
impaired gas exchange
impairment
has potentiality actual
is applied to gas exchange
has subject of information client
A.2.10
decreased cognitive ability
decrease
has potentiality actual
is applied to ability
is perspective on cognition
has subject of information client
A.3 Examples with Focus as base category
A.3.1
risk of altered body temperature
body temperature
has judgement altered
has potentiality risk of
has subject of information client
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A.3.2
non-compliance with medication regimen
medication regimen
has perspective compliance
has judgement inadequate
has potentiality actual
has subject of information client
A.3.3
compromised family coping
coping
has judgement compromised
has potentiality actual
has subject of information family
A.3.4
ineffective thermal regulation
thermal regulation
has judgement ineffective
has potentiality actual
has subject of
...
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