The date in parentheses is the year the terminology was first recognized. For more information about each use the link for each terminology and the information in chapter 16 and see more links for some terminologies.
Nursing Specific Items from the NMDS
|Nursing Problem||Nursing Intervention||Nursing Outcome||Nursing Intensity|
Nursing Specific Terminologies
|The above three terminologies must be used together to obtain information about the nursing problem (diagnosis), intervention and outcome. The below terminologies all have terms for the nursing problem, intervention, and outcome.|
|1Omaha System (1992)||x||x||x|
|1CCC (HHCC) (1992)||x||x||x|
|4SNOMED-CT Nursing Subset||x|
1-The Omaha System and the CCC can be used "as is" without payment of royalties. Users, however, are not authorized to alter or modify them. All other nursing specific terminologies require payment of royalty. SNOMED and LOINC are usable freely by most agencies in the United States.
2-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. It is currently being mapped to SNOMED-CT.
3- SNOMED-CT (Clinical Terms) allows mapping by all the nursing specific terminologies.
4- SNOMED-CT nursing subset has not been officially recognized by the ANA, but is a legitmate standardized terminology
5-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.
See the Online Journal of Issues in Nursing topic on standardized languages for articles about standardized nursing terminologies
For a description of each of the ANA Recognized Languages see Chapter 16 in the text.
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. The needs of healthcare providers differ depending on the perspective and the needs of their discipline. Care givers require detailed information pertinent to their discipline; policy makers data that has been summarized.
There are several minimum data sets used by the the Centers for Medicare and Medicaid for health care such as the Uniform Hospital Discharge Data Set, the Long Term Care Minimum Data Set, and the Ambulatory Care Minimum Data Set. 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. Due to many circumstances, it never achieved its original purpose of being universally collected and submitted to CMS (Hobbs, 2008).
In a minimum data set, the definitions of each element need to be clear and unambiguous. The current U.S. Nursing Minimum Data Set contains only the names and definitions for the elements, not the terminology used as data for each element. 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 a nursing diagnosis is NOT defined by the US Nursing Minimum Data Set (NMDS). The standardized terminology from the North American Nursing Diagnoses Association International (NANDA) is one of the American Nurses Association (ANA) recognized standard nursing terminologies that can be used to collect the nursing diagnosis (problem) element in the NMDS. However, with the exception of the International Classification of Nursing Practice, the ANA nursing specific standardized terminologies, use nursing diagnosis based on NANDA.
There are two minimum data sets recognized by the ANA. The Nursing Minimum Data set (page 285) and the Nursing Management Minimum Data Set (NMMDS) (page 286).
For too long nursing data has not been seen as valuable, giving rise to the perception that nursing is only a handmaiden to medicine. With this perception, nursing documentation is seen as useful only as evidence that the physician's orders have been carried out. For this reason it seldom demonstrates the knowledge level required by today's nurse with the result that nursing is often discounted and a prime target for cost cutting.
Thus nursing's contribution to health care is invisible. Nursing documentation is not included in data that is submitted by health care agencies to governments or other regulating entities for use in health care planning, thus an important element is missing in patient care. If nursing data is to be included in submitted data it is imperative that it be computerized. Computerizing the data requires the solution to two problems, deciding what date is important to patient care, and standardizing the terminology used to represent this data. For a computer to use data, a standardized term must be used to represent the same concept.
Standardized terminologies permit several operations. One, the use of data in an aggregated (the same piece of data for many patients) format to determine outcomes and to plan for needed regional, state, national, and international health care, and two, the ability to find information (literature or clinical records) about the clinical implications for a given term.
Very simply a standardized terminology is a list of terms with agreed upon definitions so that when a term is used it means the same thing to everyone. Often the terms are organized into a taxonomy. Although technically the term "taxonomy" refers to the classification of living organisms, the concepts of organization from a stated principle are used in healthcare taxonomies. For example, pain is a concept that can contain the concepts acute pain or chronic pain. In taxonomies, data from various categories can be aggregated.
Some terminologies are what are called multi-axial, that is, terms can be matched to different organizing principles or axis. The International Classification of Nursing Practice is built on this principle.
In the United States the American Nurses Association (ANA) has spearheaded efforts to coordinate the various minimum data sets and standardized nursing terminologies. The ANA Committee for Nursing Practice Information Infrastructure (CNPII) evaluates 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). Note that the ANA "recognizes" terminologies, it does not "approve" them. ANA Recognized terminologies.
Nursing Minimum Data Set (NMDS) (1999)
Nursing Management Minimum Data Set (NMMDS) (2003)
Hobbs, J. (2008). Naming Power: a Historical Analysis of Clinical Information Systems, 1970-1990 [Electronic version at http://gradworks.umi.com/33/28/3328695.html], University of Pennsylvania: 254.
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.
Created January 15, 2012