Terminologies

Terminologies

Offers systematic standardized ways of describing nursing practice and include data sets, taxonomies, nomenclatures and classification system.

●Focus on the patient and care process not reimbursement or mortality.

Concept Representation

Set of terms and relationships that describes the phenomena, processes, and practices of discipline

Data Elements

Terms for which data are collected and for which values are assigned

Data Set

Specific, purposeful group of data elements, representing a subset of concepts within a discipline.

Nursing Minimum Data Set by Dr. Harriet Werly 

Foundational work for nursing languages and represents the first attempt to standardize the collection of essential nursing data.

Taxonomy

●Study of classification and simultaneously refers to the end of the product of a classification.

●Method of classifying  a  vocabulary provide schemas(representation of concept)  to help classify the entities and define  the relationship between them.

Classification

●Ordering of entities into groups according to a set of criteria as well as the end result of the ordering.

●systematic arrangement according to similar group

Nursing Intervention Classification (NIC)

●Contains 514 nursing interventions that describe the treatments nurses perform, updates linkages with NANDA diagnoses, and core interventions identified for 44 specialty area.

Nursing Outcomes Classification (NOC)

 

●330 research-based outcomes to provide standardization of expected patient, caregiver, family, community outcomes for measuring the effect of nursing intervention.

Clinical Care Classification (CCC)

•Formerly known as Home Health Care Classification (HHCC)

●Research-based nomenclature designed to standardize the terminologies for documenting nursing care in all clinical care settings.

Omaha System

●Most recent in November 2004

●Includes assessment component (Problem Classification Scheme) , intervention component (Intervention Scheme), and outcomes component (Problem Rating Scale for Outcomes)

 

Perioperative Nursing Data Set (PNDS)

Provides universal language for perioperative nursing practice and education and a framework to standardize documentation

SNOMED CT

Core clinical terminology containing over 370,000 healthcare concepts with unique meanings and formal logic based definitions organized into multiple hierarchies.

ABC Codes

Provide mechanism for coding integrative health interventions by clinician by state location for administrative billing and insurance claims.

Patient Care Data Set (PCDS)

●Terms and codes for patient problems, therapeutic goals, and patient care orders.

●Developed Dr. Judith Ozbolt

International Classification for Nursing Practice (ICN)

Developed by international nursing community under sponsorship by international Council of Nurses (ICN)

Nursing Management Minimum Data Set (NMMDS)

Describe the context and environment of nursing practice, and includes terms for nursing delivery unit/service, patient population, care delivery method, personnel characteristics, and financial resources.

Concepts (thought or reference)

Unit of knowledge created by unique combination of characteristics

Characteristics

An abstraction of a property of an object or of a set of objects.

Object (referent)

Anything perceivable or conceivable

Term (symbol)  

Verbal designation of a general concept in a specific subject field.

Schemata

domain specific knowledge about the typical constellations of entities, attributes, and events in the real world. May be supported by either formal or informal composition rules

GALEN Program

Directly support clinical applications to supporting the authoring, maintenance, and quality assurance of other kinds of terminologies

GRAIL (GALEN representation and integration language)

Ontology language for representing concepts and their interrelationships

SNOMED RT

Reference terminology optimized for clinical data retrieval and analysis

Emerging Approaches

●OWL (Web ontology language)

●Intended for use where application, rather than humans, are to process information.