- Book and Website
- Information to Supplement the Text
- Websites In This Chapter
- Read Jeanne's Blog
Nursing Documentation in the Age of the EHR
- ANA Recognized Standardized Terminologies, Background and Information
- Glossary for Standardized Terminologies
- Interface or Reference Terminology
- Slide Show Theory of Mapping
- Terminologies Further Explained
Background of ANA Involvement. Some good history. Unfortunately, NIDSEC mentioned here is no longer is active.
Pace, Diane (2008). ANA Committee for Nursing Practice Information Infrastructure. Article from the Tennessee Nurse describing the role of the CNPII.
Zielstorff, Rita. (1998) Characteristics of Nomenclature from Informatics Perspective. Online Journal of Issues in Nursing 3(2). Written by one of the best clinical nursing informaticists, this article still has excellent ideas.
Other articles on this subject can be found at
Lundberg, C., Warren, J.., Brokel, J., Bulechek, G., Butcher, H., McCloskey Dochterman, J., Johnson, M., Mass, M., Martin, K., Moorhead, S., Spisla, C., Swanson, E., & Giarrizzo-Wilson, S. (June, 2008). Selecting a Standardized Terminology for the Electronic Health Record that Reveals the Impact of Nursing on Patient Care. Online Journal of Nursing Informatics (OJNI) 12 (2). An excellent article that describes each terminology and how they are integrated into SNOMED-CT. Each author is an expert in one of the realms addressed.
NANDA History. Divided into decades, this site provides an accurate picture of the development of NANDA. (Added October 16, 2009)
Nursing Problem List Subsets of SNOMED CT. "The SNOMED CT® encoded Nursing Problem List Subset, intended for use in patients’ problem lists, is an output of the Unified Medical Language System® (UMLS®) Metathesaurus® that is based on nursing diagnosis concepts found within the Metathesaurus."
Perioperative Nursing Data Set. Petersen, Carol. (1999). Implications of Implementing a Standardized Nomenclature in the Perioperative Nursing Environment.
SNOMED-CT History and other information.
Schwirian, P, & Thede, L. (2011).Informatics: The Standardized Nursing Terminologies: A National Survey of Nurses’ Experiences and Attitudes. Online Journal of Issue in Nursing 16(2).
Morris, K. (2010) Nursing Makes Cents: Finding the Dollars in What Nurses Do. An excellent article focusing mainly on the intensity of nursing care which is the one nursing specific item from the Nursing Minimum Data Set that none of the terminologies address. Links to some excellent resources at the end. Addresses one of the missing values in current nursing terminologies, "nursing intensity." Great list of references as to how to determine nursing costs.
Thede, L.Q. (2008). Informatics: The Electronic Health Record: Will Nursing Be on Board When the Ship Leaves? Online Journal of Issues in Nursing 3(2). A discussion of the need for nurses to find ways to represent nursing in an electronic record.
USA Nursing Minimum Data Set (NMDS) http://www.nursing.umn.edu/ICNP/USANMDS/
Nursing Management Minimum Data Set (NMMDS) http://www.nursing.umn.edu/ICNP/USANMMDS/
Clinical Care Classification (CCC) http://www.sabacare.com/
North American Nursing Diagnosis Association - International (NANDA-I) http://www.nanda.org/
Nursing Interventions Classification (NIC)
NIC (No longer available). Instead to see NICs strengths only see
Nursing Outcome Classification
Noc.htm (No longer available). Instead to see NOCs strengths only see http://www.nursing.uiowa.edu/cncce/nursing-outcomes-classification-strengths
Omaha Home Health Care System http://www.omahasystem.org/
Patient Care Data Set (Retired) http://www.ncvhs.hhs.gov/990518t3.pdf
Perioperative Nursing Data Set
PNDSModel/ (No longer available). Instead see www.duke.edu/~newki001/PNDS_xerfile.pdf
International Classification of Nursing Practice (ICNP) http://www.icn.ch/pillarsprograms/international-classification-for-nursing-practicer/
Logical Observation Identifiers Names & Codes (LOINC) http://loinc.org/
Systematized Nomenclature of Medicine (SNOMED-CT) http://www.ihtsdo.org/snomed-ct/
Alternative Billing Codes (ABC) http://www.alternativelink.com/ali/home/
NMDS. Retrieved February 11, 2011, from http://www.nursing.umn.edu/ICNP/USANMDS/
International Council of Nurses. (2010). International Nursing Minimal Data Set (i-NDMS). Retrieved February 12, 2011,
American Nurses Association. (2007, June 5). Relationships among ANA recognized data element sets and terminologies. Retrieved February 16, 2011, from http://www.nursingworld.org/npii/relationship.htm. (No longer available)
Association of periOperating Room Nurses. (2011). The PNDS model. Retrieved February 11, 2011,
/PNDSModel/ (No longer available)
Center for Nursing Classification & Clinical Effectiveness. (n.d.-a). Nursing Interventions Classification (NIC). Retrieved February 13, 2011, from http://www.nursing.uiowa.edu/excellence/nursing_knowledge/clinical_effectiveness/ nicoverview.htm (No longer available)
Center for Nursing Classification & Clinical Effectiveness. (n.d.-b). Nursing Outcomes Classification (NOC). Retrieved February 11, 2011, from http://www.nursing.uiowa.edu/excellence/nursing_knowledge/clinical_effectiveness/ nocoverview.htm (No longer available)
Center for Nursing Minimum Data Set Knowledge. (2010, January 7). USA NMMDS. Retrieved February, 2011, from http://www.nursing.umn.edu/ICNP/USANMMDS/
Free Merriam-Webster Dictionary. (2011). Ontology. Retrieved February 10, 2011, from http://www.merriamwebster.com/dictionary/ontology
Gordon, M. (1998). Nursing nomenclature and classification system development. Online Journal of Issues in Nursing, 3(2). Retrieved from
International Council of Nursing. (2009). Nursing matters: International Classification for Nursing Practice. Retrieved February 16, 2011, from http://www.icn.ch/images/stories/documents/publications/fact_sheets/3a_FS-ICNP.pdf
International Council of Nurses. (2011). International Nursing Minimal Data Set (i-NDMS). Retrieved March 31, 2012 from http://www.icn.ch/pillarsprograms/internationalnursing-minimum-data-set-i-nmdsseptember-2007/. (No longer available) Instead go to
International Health Terminology Standards Development Organisation. (n.d.). History of SNOWMED CT. Retrieved February 16, 2011, from http://www.ihtsdo.org/snomed-ct/history0/
Kripps, B. J. (2008). Toward standardized nursing terminology: The next steps. Caring Newsletter, 23(3), 4–8. Retrieved from http://www.thefreelibrary.com/oward+standardized+nursing+terminology%3A+the+
Lunney, M. (2008). Critical need to address accuracy of nurses’ diagnoses. Online Journal of Issues in Nursing, 13(1). Retrieved from http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/
McCormick, K., & Jones, C. (1998). Is one taxonomy needed for health care vocabularies and classifications? Online Journal of Issues in Nursing, 3(2). Retrieved from http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/
Medical News Today. (2007, January 15). Hospital death rate study reveals wide variations and stresses importance of registered nurses. Medical News Today. Retrieved February 8, 2011, from http://www.medicalnewstoday.com/articles/60785.php
North American Nursing Diagnosis Association. (2011). Nursing diagnosis frequently asked questions. Retrieved February 13, 2011, from http://www.nanda.org/NursingDiagnosisFAQ.aspx#NDxBasics
Needleman, J., Buerhaus, P. I., Mattke, S., Stewart, M., & Zelevinsky, K. (2001). Nurse staffing and patient outcomes in hospitals (2001): Executive summary. Retrieved February
8, 2011, from ftp://ftp.hrsa.gov/bhpr/nursing/staffstudy/staffexecsum.pdf
Nightingale, F., & Goldie, S. M. (1997). Letters from the Crimea, 1854–1856. Retrieved from http://preview.tinyurl.com/2auahra
Regenstrief Institute. (2011). Logical Observation Identifiers Names and Codes (LOINC®) ). Retrieved February 16, 2011, from http://loinc.org/
Rutherford, M. (2008). Standardized nursing language: What does it mean for nursing practice? Online Journal of Issues in Nursing, 13(1). Retrieved from http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/
Saba, V. K. (2011). Clinical Care Classification System™. Retrieved February 11, 2011, from http://www.sabacare.com/
School of Mathematics and Statistics, St. Andrews University Scotland. (2003). Florence Nightingale. Retrieved July 31, 2010, from http://www-history.mcs.st-andrews.ac.uk/Biographies/Nightingale.html
The Omaha System. (2010). Retrieved February 11, 2011, from http://www.omahasystem.org/
U.S. National Library of Medicine. (2010). SNOWMED ClinicalTerms®. Retrieved February 16, 2011, from http://www.nlm.nih.gov/research/umls/Snomed/snomed_main.html
Created January 15, 2012