|
|
|
ANA Recognized Standardized Terminologies for Use in Computerizing Nursing Documentation |
Last Updated: November 8, 2006
Nursing data at present is too often confined to a paper record and used only for individual patient care. It is never included in data that is submitted by health care agencies to governments and other regulating entities for use in health care planning. This creates a situation in which nursing's contribution to health care is invisible. If nursing data is to be included in submitted data it is imperative that it be computerized. Computerizing the data requires two tasks. One, decide what constitutes nursing data and two, decide on the terminology that will be used to represent the agreed upon data. These two tasks are represented in the US nursing by minimum data sets and standardized sets of terminology that support nursing practice.
Technically, the term, data set, means "... a collection of data elements organized for a specific purpose." (Hunter, 2001). Under this definition, the term includes both minimum data sets and standardized terminologies. In nursing this leads to confusion. Thus, in these pages, the term minimum data set and standardized terminology will be used to differentiate between the two.
The United States Health Information Policy Council defines a minimum data set as the "minimum set of items of information with uniform definitions and categories, concerning a specific aspect or dimension of the health care system which meets the essential needs of multiple data users." (Health Information Policy Council, 1983, p. 3 as cited in Werley, Ryan & Zorn, 1995.) Thus, the minimum data required depends on the circumstances. Meeting the needs of care givers requires data that is different than the data required by those who make policy. The first requires detailed information, the second data that has been summarized. This latter need is met by minimum data sets.
There are several minimum data sets in health care. Table 13-4 in Chapter 13 lists some of these. None, however, contain nursing sensitive data. Yet data from these data sets are used in making decisions about health care.
To overcome this deficiency, a Nursing Minimum Data Set (NMDS) was conceived in the 1970s and birthed in the 1980's. Unfortunately, it is not well known or used. It is too often confused with other minimum data sets.
In a minimum data set, the definitions of each piece of data need to be clear and unambiguous. The definitions in the current US nursing minimum data set pertain only to what constitutes a category, not the terminology used as data in the categories. For example, in the NMDS nursing diagnosis is defined as "A clinical judgment made by a nurse about a human response to an actual or potential health problem, the intervention for which nurses are accountable." (Werley, Devine & Zorn, 1988, p. 31.). The terminology used to represent the nursing diagnoses themselves, however, is NOT defined by the US Nursing Minimum Data Set (NMDS). The vocabulary prepared by the North American Nursing Diagnoses Association (NANDA) is one of the American Nurses Association (ANA) recognized standard nursing terminologies that can be used to collect the nursing diagnosis element in the NMDS.
Other countries have developed nursing minimum data sets also. Some of the purposes of these are described in Chapter 13 in the text.
It is important that we promote the NMDS, along with standardized terminologies if we wish nursing data to be used in health care planning. This same data can also demonstrate the value that nurses add to health care.
Because in the US, a minimum data set only designates what to collect, not what words will be used in the collection process, standardized terminologies are needed to collect the data. A standardized terminology will ensure that when a given term is used it means the same thing to everyone. Additionally, the terms need to be organized so that they can be used not only individually, but together with related terms. This is accomplished by classifying the terms into a taxonomy.
Whether a set of standardized terminologies is officially termed a vocabulary, a taxonomy, combinatorial vocabulary, or formal language (the Ingenerf typologies) is not important for our purposes here. In presenting this summary of the standardized terminologies the term standardized nursing terminology will be used to represent all of them.
In the United States the American Nurses Association (ANA)has spearheaded efforts to coordinate the various minimum data sets and standardized nursing terminologies. Committees in this organization evaluate minimum data sets and standardized terminologies submitted to them to see if they meet specific criteria. This criteria includes a rationale for the development of the terminology, that it be clinically useful and that the terms be clear and unambiguous (Beyea, 2000). What follows is a list of the two minimum data sets and 11 standardized nursing terminologies that have been recognized by the American Nurses Association as of this date. (Feb. 1, 2003)
Nursing Minimum Data Set (NMDS) (1999)
Nursing Management Minimum Data Set (NMMDS) (2003) PDF File
The date in parentheses is the year the terminology was first recognized. Terminologies in green text are retired.
| Standardized Terminology | Nursing Elements of the NMDS | Classification Schemes | |||
| Nursing Diagnosis | Nursing Intervention | Nursing Outcome | Nursing Intensity | ||
| NANDA-I (North American Nursing Diagnosis Association International) (1992) | x | Nursing Diagnosis | |||
| NIC (Nursing Interventions Classification) (1992) | x | Interventions | |||
| NOC (Nursing Outcomes Classification (1997) | x | Outcomes | |||
| The above three are intended to be used together. Currently in process is a classification scheme to unite all three of these. However, they are still 3 different terminologies. | |||||
| 1-Omaha System (1992) |
x | x | x | 1) Problems 2) Outcomes 3) Interventions |
|
| 1-CCC (Clinical Care Classification - Formerly the HHCC Home Health Care Classification) (1992) | x | x | x | 1) Nursing Diagnoses & Outcomes 2) Interventions |
|
| Patient Care Data Set (1998) This terminology was retired.in 2006. |
x | x | x | ||
| PNDS (Perioperative Nursing Data Set) (1999) | x | x | x | 1) Nursing Diagnoses 2) Interventions & Goals |
|
| 2-SNOMED-CT (1999) Systematized Nomenclature of Medicine. SNOMED-CT has replaced SNOMED-RT which has been retired. SNOMED-CT has received recognition from the ANA in 2003. | x | x | x | ||
| 3-ICNP International
Classification for Nursing Practice (2000) |
x | x | x | 1) Nursing Diagnosis & Outcomes 2) Nursing Interventions |
|
| 4-Alternative Link (2000) | x | ||||
| 1--LOINC - Logical Observation Identifiers Names & Codes (2002) | x | ||||
1- These two languages can be used "as is" without payment of royalties. Users, however, are not authorized to alter or modify them.
2- SNOMED-CT (Clinical Terms) allows mapping to the nursing problems (diagnoses) for NANDA II, the Omaha system, HHCC, and the PNDS. Interventions for NIC, Omaha, HHCC, and PNDS and outcomes for NOC, Omaha, HHCC, and the PNDS.
3. This language is copyrighted. Written permission from the International Council of Nurses is required, but no fee is required for non-commercial use. A small fee is charged for-profit use. http://www.icn.ch/
4-Alternative Link's products support electronic and paper claims processing and fee structures for providers, health care payers, managed care organizations and affiliate organizations. Although ANA recognized, it has a purpose different than the others.
For information about how nursing standardized terminologies are used by vendors see NIDSEC (http://www.ana.org/nidsec/)
See the Online Journal of Issues in Nursing topic on standardized languages for several articles about standardized nursing terminologies
For more explanation about the uses of the ANA recognized standardized nursing terminologies, and the Unified Nursing Language, see Standardized Terminology Types.
For a description of each of the ANA Recognized Languages see Chapter 13 in the text.
Beyea, S. (2000). Standardized nursing vocabularies and the perioperative nursing data set. CIN Plus 3(2), 1;5-6.
Health Information Policy Council (1983). Background paper: Uniform minimum health data sets (unpublished). Washington, DC: U.S. Department of Health and Human Services.
Hunter-Milholland, K. (2001). Electronic Health Records. In S. Englebardt & R. Nelson, (Eds.) Health care informatics: An interdisciplinary approach. St. Louis: Mosby, pp 209-230.
Werley, H. H., Devine, E. C. & Zorn, C. R. (1988). Nursing Minimum Data Set data collection manual. Milwaukee, WI: University of Wisconsin-Milwaukee School of Nursing.
Werley, H.,H., Ryan, P., & Zorn, C. R. (1995). The nursing minimum data set (NMDS): A framework for the organization of nursing language. In Lang, N. M. (Ed.) Nursing Data System: The Emerging Framework. American Nurses Association: Washington, DC., pp 19 - 30.
Last Updated: March 18, 2003
For questions or broken links please email the author .
Copyright 2003/2008 Linda Q. Thede
All rights reserved