SIST EN ISO 18104:2024
(Main)Health informatics - Categorial structures for representation of nursing practice in terminological systems (ISO 18104:2023)
Health informatics - Categorial structures for representation of nursing practice in terminological systems (ISO 18104:2023)
This document specifies the characteristics of categorial structures, representing nursing practice. The overall aim of this document is to support interoperability in the exchange of meaningful information between information systems in respect of nursing diagnoses, nursing actions and nurse sensitive outcomes. Categorial structures for nursing diagnoses, nursing actions, nurse sensitive outcomes and associated categories support interoperability by providing common frameworks with which to
a) analyse the features of different terminologies, including pre- and post-coordinated expressions, those of other healthcare disciplines, and to establish the nature of the relationship between them,[3][4][5][6][7][8]
b) develop terminologies for representing nursing diagnoses, nursing actions,[9][10][11][12] and nurse sensitive outcomes,
c) develop terminologies that are able to be related to each other,[3][8][13] and
d) establish relationships between terminology models, information models, including archetypes, and ontologies in the nursing domain.[14][15][16][45]
There is early evidence that the categorial structures can be used as a framework for analysing nursing practice,[17] for developing nursing content of electronic record systems,[18][19] document the value of nursing services provided and to make nursing’s contribution visible[16][36][47][50].
Medizinische Informatik - Kategoriale Strukturen zur Darstellung der Pflegepraxis in terminologischen Systemen (ISO 18104:2023)
Informatique de santé - Structures catégorielles destinées à la représentation des pratiques de soins infirmiers dans les systèmes terminologiques (ISO 18104:2023)
Le présent document spécifie les caractéristiques des structures catégorielles, représentant les pratiques de soins infirmiers. Son objectif général est d’assurer l’interopérabilité dans l’échange d’informations significatives entre les systèmes d'information en matière de diagnostics infirmiers, d’actions infirmières et de résultats sensibles aux soins infirmiers. Les structures catégorielles relatives aux diagnostics infirmiers, aux actions infirmières et aux résultats sensibles aux soins infirmiers et les catégories associées favorisent l'interopérabilité en proposant des cadres communs permettant d’effectuer les opérations suivantes:
a) analyser les caractéristiques des différentes terminologies, y compris les expressions pré- et post-coordonnées, celles des autres disciplines du domaine des soins de santé, et établir la nature de leurs relations[3][4][5][6][7][8];
b) élaborer des terminologies visant à représenter les diagnostics infirmiers, les actions infirmières[9][10][11][12], et les résultats sensibles aux soins infirmiers;
c) élaborer des terminologies à même d'être liées les unes aux autres[3][8][13]; et
d) établir des relations entre les modèles de terminologie, les modèles d'information (y compris les archétypes) et les ontologies dans le domaine des soins infirmiers[14][15][16][45].
Il a déjà été démontré que les structures catégorielles peuvent servir de cadre à l'analyse des pratiques de soins infirmiers[17] pour élaborer le contenu des soins infirmiers dans les systèmes de dossiers informatisés,[18][19] consigner la valeur des services de soins infirmiers prodigués et rendre visible la contribution apportée par les soins infirmiers[16][36][47][50].
Zdravstvena informatika - Kategorijske strukture za predstavitev prakse bolniške nege v terminoloških sistemih (ISO 18104:2023)
Ta dokument določa lastnosti kategorijskih struktur za predstavitev prakse bolniške nege. Splošni namen tega dokumenta je podpora interoperabilnosti pri izmenjavi pomembnih informacij med informacijskimi sistemi v zvezi z diagnozami, postopki in občutljivimi izidi bolniške nege. Kategorijske strukture za diagnoze, postopke in občutljive izide bolniške nege ter povezane kategorije podpirajo interoperabilnost z zagotavljanjem skupnih okvirjev za:
a) analizo funkcij različnih terminologij, vključno s predhodno in naknadno usklajenimi izrazi ter izrazi z drugih področij zdravstva, in ugotovitev narave razmerja med njimi;
b) razvoj terminologij za predstavljanje diagnoz, postopkov in občutljivih izidov bolniške nege;
c) razvoj terminologij, ki bodo medsebojno povezane, ter
d) ugotovitev razmerij med terminološkimi modeli, informacijskimi modeli, vključno z arhetipi, in ontologijami na področju bolniške nege.
Obstajajo začetni dokazi, da je mogoče kategorijske strukture uporabiti kot okvir za analizo prakse bolniške nege, razvoj vsebin, povezanih z bolniško nego, za sisteme elektronskih zapisov, dokumentiranje vrednosti zagotovljenih storitev bolniške nege in ozaveščanje o prispevanju bolniške nege.
General Information
Relations
Standards Content (Sample)
SLOVENSKI STANDARD
01-junij-2024
Nadomešča:
SIST EN ISO 18104:2014
Zdravstvena informatika - Kategorijske strukture za predstavitev prakse bolniške
nege v terminoloških sistemih (ISO 18104:2023)
Health informatics - Categorial structures for representation of nursing practice in
terminological systems (ISO 18104:2023)
Medizinische Informatik - Kategoriale Strukturen zur Darstellung der Pflegepraxis in
terminologischen Systemen (ISO 18104:2023)
Informatique de santé - Structures catégorielles destinées à la représentation des
pratiques de soins infirmiers dans les systèmes terminologiques (ISO 18104:2023)
Ta slovenski standard je istoveten z: EN ISO 18104:2023
ICS:
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.
EN ISO 18104
EUROPEAN STANDARD
NORME EUROPÉENNE
December 2023
EUROPÄISCHE NORM
ICS 35.240.80 Supersedes EN ISO 18104:2014
English Version
Health informatics - Categorial structures for
representation of nursing practice in terminological
systems (ISO 18104:2023)
Informatique de santé - Structures catégorielles Medizinische Informatik - Kategoriale Strukturen zur
destinées à la représentation des pratiques de soins Darstellung der Pflegepraxis in terminologischen
infirmiers dans les systèmes terminologiques (ISO Systemen (ISO 18104:2023)
18104:2023)
This European Standard was approved by CEN on 17 November 2023.
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.
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© 2023 CEN All rights of exploitation in any form and by any means reserved Ref. No. EN ISO 18104:2023 E
worldwide for CEN national Members.
Contents Page
European foreword . 3
European foreword
This document (EN ISO 18104:2023) 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 June 2024, and conflicting national standards shall be
withdrawn at the latest by June 2024.
Attention is drawn to the possibility that some of the elements of this document may be the subject of
patent rights. CEN shall not be held responsible for identifying any or all such patent rights.
This document supersedes EN ISO 18104:2014.
Any feedback and questions on this document should be directed to the users’ national standards
body/national committee. A complete listing of these bodies can be found on the CEN website.
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, France, Germany, Greece, Hungary, Iceland,
Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, Netherlands, Norway, Poland, Portugal, Republic of
North Macedonia, Romania, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland, Türkiye and the
United Kingdom.
Endorsement notice
The text of ISO 18104:2023 has been approved by CEN as EN ISO 18104:2023 without any modification.
INTERNATIONAL ISO
STANDARD 18104
Third edition
2023-12
Health informatics — Categorial
structures for representation of
nursing practice in terminological
systems
Informatique de santé — Structures catégorielles destinées à la
représentation des pratiques de soins infirmiers dans les systèmes
terminologiques
Reference number
ISO 18104:2023(E)
ISO 18104:2023(E)
© ISO 2023
All rights reserved. Unless otherwise specified, or required in the context of its implementation, no part of this publication may
be reproduced or utilized otherwise in any form or by any means, electronic or mechanical, including photocopying, or posting on
the internet or an intranet, without prior written permission. Permission can be requested from either ISO at the address below
or ISO’s member body in the country of the requester.
ISO copyright office
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Phone: +41 22 749 01 11
Email: copyright@iso.org
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Published in Switzerland
ii
ISO 18104:2023(E)
Contents Page
Foreword .iv
Introduction . vi
1 Scope . 1
2 Normative references . 1
3 Terms and definitions . 1
3.1 General terms . 2
3.2 Categories of healthcare entities for nursing diagnoses . 4
3.3 Sub-categories of healthcare entities applicable to a clinical assessment including
nursing diagnoses . 5
3.4 Categories of healthcare entities for NursingActions not previously specified. 6
3.5 Sub-categories of healthcare entities for Nursing Actions and its sub-categories
not previously specified. . 7
3.6 Categories of healthcare entities for Nurse Sensitive Outcomes . 8
3.7 Sub-categories of healthcare entities for nurse sensitive outcomes . 9
4 Semantic links .10
4.1 ‘Representation relation’ to ‘Nursing Diagnosis’ . 10
4.2 ‘Representation relation’ to ‘nursing action’ . 13
4.3 List of domain constraints for nurse sensitive outcome, including its sub-
categories and their attributes . 15
5 Categorial structures — Requirements .17
6 Categorial structure for representing nursing diagnoses .17
7 Categorial structure for representing nursing actions .18
8 Categorial structure for representing nurse sensitive outcomes .19
Annex A (informative) Nursing diagnosis, nursing actions and nurse sensitive outcomes in
context .20
Annex B (informative) Guidance for using categorial structures .29
Bibliography .33
iii
ISO 18104:2023(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
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www.iso.org/iso/foreword.html.
This document was prepared by Technical Committee ISO/TC 215, Health informatics, in collaboration
with the European Committee for Standardization (CEN) Technical Committee CEN/TC 251, Health
informatics, in accordance with the Agreement on technical cooperation between ISO and CEN (Vienna
Agreement).
This third edition cancels and replaces the second edition (ISO 18104:2014), which has been technically
revised.
The main changes are as follows:
— more comprehensive representation of nursing practice;
— inclusion of nurse sensitive outcomes, its sub-categories representing known confounding variables
and their relationship with the care process;
— inclusion of reference to ISO 13606-2 and openEHR RIM;
— inclusion of reference to ICNP into the SNOMED CT® terminology;
— representation of the nursing action ‘Assessment’ as an Observation which is represented as a sub-
category of NursingAction;
— recognition of the collaborative roles of nurses (and midwives) with their subject of care to inform
actions and assessments;
— inclusion of a goal/ expected outcome category;
— inclusion of a number of specified sub-categories enabling the differentiation between Nursing
Actions and actions undertaken by others, as listed in a new category titled Outcome Causation;
iv
ISO 18104:2023(E)
— category definitions were reviewed and updated;
— definitions are provided for all new categories and sub-categories.
Any feedback or questions on this document should be directed to the user’s national standards body. A
complete listing of
...
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