Advanced
Terminology
Systems
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
Standardized Terminology
Consistsof nursing concepts that
represent the domain* of Nursing
Must include standardized data
the represent the essential
building blocks* for nursing
practice.
The US Institute of Medicine
(IOM) in 2012 Report
recommended that the capture of
clinical care data is needed for better
patient care coordination &
management
It stated that our patient care data is
poorly captured and managed & our
evidence poorly used.
Recommended that to be usable , the
standardized data must be captured
in real time and at the point of care.
How to convey important Data and Information to others?
The communication must be
understood by the listener and be
interpreted as having meaning.
Thisis 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 providers
Increased visibility of nursing
interventions
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’sdevelopment 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
(ANA)
operates a process of de jure
standardization through its
Committee For Nursing Practice
Information Infrastructure
Council on computer Applications
in Nursing (CCAN)
1985 – The ANA initiated the CCAN
which promoted to become involved
in the integration of computer based
applications in nursing practice,
education and research.
1992 – CCAN’s name was changed
to Database Steering Committee;
developed the criteria for a nursing
terminology.
Standardized Nursing
Terminologies
ABC Codes (Alternative Billing Codes)
CCC (Clinical Care Classification)
NMDS (Nursing Minimum Data Set)
NANDA (North American Nursing
Diagnosis Association)
NIC (Nursing Intervention
Classification)
NOC (Nursing Outcomes
Classification)
Standardized Nursing
Terminologies
Omaha System
PNDS (Peri-operative Nursing
Data Set)
ICNP (International Classification
of Nursing Practice)
LOINC (Logical Observation
Identifiers Names & Codes)
SNOMED (Systematized
Nomenclature of Medicine)
Standardized Nursing
Terminologies
ABC (Alternative Billing Codes)
Code
• Mechanism for coding integrative
health interventions by clinician for
administrative billing and insurance
claims.
• provide a more detailed description of
health care services to assure
appropriate reimbursement.
Standardized Nursing
Terminologies
ABC (Alternative Billing Codes)
Code
• 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)
Code
• 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 code.
• The ABC code is recognized by the
American Nurses Association
(ANA)
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
intervention:
- 198 concepts in categories and sub-
categories to represent interventions,
procedures, treatments, and
activities.
The NMDS
(Nursing Minimum Data Set)
Identifies
essential,
common core Intended for use
data elements in all settings
to be collected where nurses
for all patients/
clients receiving
provide care
nursing care
a. Nursing
Care
The
NMDS
includes
three
categories of
elements
b. Patient
c. Service
demographic
elements
s
c. Service elements
• Unique facility or agency
number elements
a. Nursing Care • Unique patient health record
• Nursing Diagnosis number
• Nursing Intervention • Unique number of principle
• Nursing Outcome registered
• Intensity of Nursing nurse
care • Episode admission
• 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 International”
setof nursing diagnosis helping
a practitioner to codify a clinical
judgment about an individual,
family, or community and their
response to actual or potential
health problems.
NANDA-I “North American
Nursing Diagnosis International”
Each nursing diagnosis actual or
potential health problem has:
description, definition, defining
characteristics (manifestations,
signs, symptoms) 13 domains, 7
axes(dimensions)
Nursing Interventions
Classification (NIC)
is a comprehensive, research-based,
standardized classification of nursing
interventions.
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 interventions
Nursing Outcomes Classification
(NOC)
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 references
The Omaha System
Applications for Community Health
Nursing
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:
Itincludes 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
Outcomes,
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
(PNDS).
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
records.
LOINC “Logical Observation
Identifiers, Names, and Codes”
Terminologies for laboratory
and clinical observations
For recording a single
observation, measurement,
test result.
SNOMED CT (Systematized
Nomenclature of
Medicine -- Clinical Terms)
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.
