Vocabulary Specific to Standardized Terminologies
The same data from multiple records. For example, nursing diagnoses from all patients with the medical diagnosis of diabetes.
The lowest level into which data can be divided. For example, for the concept name, first name, middle initial, and last name are all at the atomic level. Name is not. Blood pressure is not at the atomic level, but systolic pressure is. In electronic databases, if one does not use atomic level data, the uses to which the data can be put are reduced. For example if blood pressure is entered as 120/70, it cannot be graphed. To graph it, the systolic and diastolic must be entered into separate "fields," or cells in spreadsheet or table terminology.
The unifying principle, dimension, or criteria in a classification scheme around which terms are grouped.
In NANDA Terminology II, the axes are a dimension of the human response used to make a nursing diagnosis. The axes are the diagnostic concept, time, unit of care, age, health status, descriptor, and topology (parts or regions of the body).
In the International Classification of Nursing Practice (ICNP) the axes are: Client, Focus (the problem), Judgment (opinion), Means, Time, and Location. Creating a nursing problem, intervention, or outcome in this nursing standardized terminology means combining terms from these axes. See taxonomy, mono-axial taxonomy and multi-axial taxonomy.
A term used to describe a data collection that is too large to analyze using on hand tools. Often used to describe data collected in healthcare. See http://en.wikipedia.org/wiki/Big_data
Part of the International Classification of Nursing Practice. Now referred to as subsets.
Classification Scheme (System)
Set of mutually exclusive designations structured to support aggregation. (ISO 17117)
Exhaustive set of mutually exclusive categories to aggregate data at a pre-prescribed level of specification for a specific purpose. (ISO 17115)
An assignment of objects into groups based upon characteristics which the objects have in common, e.g. origin, composition, structure, function, etc.
A scheme in which objects are classified based on given characteristics. For example, influenza is a type of infectious disease. Infectious disease represents a broader concept, while influenza is a narrower concept. Influenza could be further classified according to its type into even narrower categories. To classify objects, rules are set up that determine into what category, and at what level, a given object (or term) belongs. The rules used in a classification are decided by those who design the classification system. Often consists of a mono-axial or multi-axial taxonomy.
Clinical Data Repository
In simple terms, a collection of patient data that is structured so that it can be analyzed many different ways. Detailed information.
Clinical Terminology
Terminology required directly or indirectly to describe health conditions and healthcare activities (ISO 17115)
Simply, terminology used to describe healthcare conditions and activities.
Coding System
A set of agreed upon symbols (frequently numeric or alphanumeric) attached to concept representation or terms in order to allow exchange of concept representations or terms with regard to their form or meaning (CEN ENV 12264) Examples include the contents of the Perioperative Nursing Data Set, and the Clinical Care Classification System.
Simply, an agreed upon set of numbers, letters, or both that represent terms. For an example, see multi-axial taxonomy.
Common Formal Language
A method of formatting a domain terminology so that the terms are nearly or completely unambigous so that any term or statement has only one meaning regardless of context. Natural language is often ambiguous, a fact dealt with by context. They allow data analysis and searching. Standardized terminologies are formal languages.
A standardized term that is created by adding together different standardized terms in a prescribed manner. See pre-coordination and post coordination
Concept
In standardized terminologies, concepts are mental representations of entities that exist in the mind.
- Concepts as mental representations, where concepts are entities that exist in the brain.
Formally described as " A unit of thought constituted through abstraction on the basis of properties common to a set of objects." (ISO 1087) or a unit of knowledge created by a unique combination of characteristics (ISO 17117).
Controlled Vocabulary
Terminological dictionary containing (and restricted to) the terminology of a specific subject field or of related subject fields and based on terminologic work. (ISO 1087/CEN ENV 12264) For example, the terms used on a multidisciplinary problem list.
Standardized terms used by the organizers of a database to describe each concept so that all items using the same term have the same meaing.Controlled vocabularies organize the information in a database (such as Library of Congress Subject Headings in their Online Catalog, or descriptors or subject terms in electronic or paper indexes).
Simply, " a way to organize knowledge for subsequent retrieval" using a given set of terms." See
http://en.wikipedia.org/wiki/Controlled_vocabulary
Data stored in a structured way so that it can be retrieved in many ways. For example, a database that contained data for one patient that consisted of nursing diagnoses and medical diagnosis, agency where treated, time of admission, time of discharge, and iatrogenic complications could be used in many ways including, but not limited to, to learn:
What nursing diagnosis were used with what medical diagnosis.
What medical diagnosis have what nursing diagnosis.
What combination of medical and nursing diagnosis have the longest length of stay.
What combination of medical and nursing diagnosis have the most iatrogenic complications.
What nursing diagnoses have the most iatrogenic complications.
For these answers to be provided, identical terms must be used to represent each piece of data. When two different terms are used to represent the same concept, the computer regards them as different and will not provide correct answers.
Data Element
A basic unit of identifiable information which can be represented in a database. First name is a data element, as is systolic blood pressure. The data element should be at the atomic level.
A unit of data for which the definition, identification, representation (term used to represent it), and permissible values are specified by means of a set of attributes. (ISO 11179-1)
A data set is a defined collection of categories of data. For example, “nursing diagnosis” is a data element in the Nursing Minimum Data Set.
A named collection of data elements in which each data element is well-defined. The elements are logically related and arranged in a prescribed manner. See minimum data set
Disjunctive
A taxonomy in which an entity has only one parent, while a parent can have many children. Many axes in a multiaxial taxonomy are disjunctive. All monoaxial taxonomies are disjunctive, but not all disjunctive taxonomies are monoaxial. The illustration under taxonomy is disjunctive.
Domain
A field of action, thought, or influence that forms the subject-matter of a single science or technology or mode of study.
The level of detail that a "term" represents. The more granular a term, the smaller the information that is represented, but also the more definitive the term. A decision that has to be made in selecting a term is how much depth is needed for the purpose of the data collection. Different purposes require different levels of granularity.
ISO 860. The attempts to match concepts and terms between terminologies. It is an extension of ISO 704. This standard details policies to harmonize concepts and terms. There are two types of harmonization, concept and term. In concept harmonization the aim is a reduction of minor differences between two or more closely related concepts. In terms harmonization single concept represented by a term are harmonized.
HITSP
Health Information Technology Standards Panel. HITSP is a cooperative partnership between the public and private sectors with the goal of providing standars to support interoperability between software applications. See http://www.hitsp.org/about_hitsp.aspx
A standardized terminology that is used for documentation of patient-related information into an electronic health record. Behind the scenes, the computer will translate these terms to a reference terminology which is coded and allows data retrieveal and analysis. Most of the nursing standardized termionlogies are interface terminologies, or have an interface component.
Often the terms from the standardized terminology are presented with a drop down list from which the user selects the appropriate term. The terms presented may be precoordinated and or may be more "natural language like" and may represent local jargon.These data entities are mapped to a reference terminology.
Used to refer to the inclusion of a term. For example, all the ANA recognized terminologies are integrated into the Uniform Medical Library System.
The old term for harmonization. One needs to remember, that translating one terminology to another is never exact.
Metadata
Metadata are data that describe other data. The term originates from the Greek meta "after" and Latin data "information." See http://en.wikipedia.org/wiki/Metadata
The minimum categories of data with uniform definitions and categories (a data set), that are developed for electronically recording, storing, and transmitting data across organizational and geographic boundaries. They are minimal because they represent the least amount of data believed necessary to capture and transmit the information needed for a given purpose. Example: US Nursing Minimum Data Set.). Some minimum data sets also contain the terms needed to express various concepts such as the NMMDS (Nursing Management Minimum Data Set).
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.
Classification around one concept that has only one axis. See the illustration in taxonomy.
A classification that uses several axes. Terms are created by making selections from more than one axis. Coding is done by using the assigned codes for the term from each axis separated by a character, often a dot.
A field that combines the fields of computer science, artificial intelligence, and linguistics with the aim of enabling computers to decipher meaning from human or natural language input. This often involves translating voice input text.
A system of designations (terms) elaborated according to pre-established rules. (ISO 1087). Examples include SNOMED CT International and the International Classification for Nursing Practice. More or less a vocabulary.
A system for naming things, especially in an area of science.
Nosology
The science of the development of diseases, the term is also used to describe the development of healthcare languages.
Ontology is a term borrowed from philosophy that "formally represents knowledge as a hierarchy of concepts within a domain, using a shared standardized vocabulary to denote the types, properties and interrelationships of those concepts.
An explicit formal specification of how to represent the objects, concepts and other entities that are assumed to exist in some area of interest and the relationships that hold among them.
http://en.wikipedia.org/wiki/Ontology_%28information_science%29
A complex phrase, or term that can be separated into other standardized terms. They are created by combing terms from the axes in a multi-axial taxonomy. In standardized terminologies they are often created for terms that are commonly used in a clinical area to provide ease of use in documentation.
A concept that is created by the user by selecting terms from different axes in a multi-axial taxonomy that contain atomic concepts. A post coordinated term is created by a human or application for instances when a pre-coordinated term is not available.
For example, a user could create the term "chest pain" by selecting "chest" from an axis of location, and "pain" from another axis.
The difference between pre-coordination and post-coordination is that in pre-coordination the term is often officially sanctioned, therefore easily usable in retrieval. In post-coordination, the term is created outside a given list and because it must be created "from scratch" can be more difficult to use, incorrect, or can result in utter nonsense. However, there is a place for both.
Reference Information Model (RIM)
A coherent, shared information model that provides a structure for information. Often seen in a diagram that guides technology developers in creating nursing diagnosis or interventions that meet given standards. The current International Organisation for Standards (ISO( is 1804:2014 an update from the 2004 version
A terminology that allows different expressions representing the same concept to be matched to that concept which can be coded and used in searching and data analysis. They are concept based versus an interface terminology which is expression based.
A reference terminology can potentially:
* Link interface expressions and statistical classifications to their formal, reference definitions.
* Generate compositional expressions from atomic concepts.
* Map between expressions in different terminologies and their formal representations in the reference terminology.
* Compare and harmonize (match) among terminologies.
*From Nursing Terminology Summit 2002 Report to AMIA. (2002). Development, Evaluation, and Use of Reference Terminology for Nursing:Progress Report from the Nursing Terminology Summit. Retrieved April 20, 2014 from http://www.j-biomed-inform.comhttp://www.j-biomed-inform.com/article/S1532-0464%2803%2900104-7/fulltext
Simply, a terminology that aims to link all the terms denoting the same concepts to a higher classification. The primary goal of a reference terminology is to enable data conversion between different schemes. Keep in mind that harmonization is not always an exact science.
Standardized Language (terminology)
A collection of "terms" with definitions for use in informational systems databases. They enable comparisons to be made because the same term is used to denote the same condition. Their development requires a great deal of work and testing. If the data captured are to be useful in improving healthcare practices they are necessary for documentation in electronic health records. One of the difficulties with standardized terminologies is that most of the work is done by volunteers who have day jobs.
In the concept of the International Classification of Nursing Practice (ICNP), this is a list of agreed upon precordinated terms useful for documenting in a specific area of nursing, such as Obstetrics, or Community Health. Formerly referred to as catalogs. They are currently being developed by various groups and work under the direction of the International Classification of Nursing Practice (ICNP) group of the International Council of Nurses (ICN) and the Center for Nursing Informatics at the University of Minesota. A list of current subsets can be found at http://www.nursing.umn.edu/icnp/icnp-catalogues/index.htm. They were formerly called catalogues.
The systematic ordering, distinguishing and naming of type groups within a subject field according to presumed natural relationships. (ISO 11179-1)
The classification of concepts in an ordered, hierarchical, predetermined system that represents relationships according to a set of "rules." Members of a "group" at the same level are distinguished from one another by stated characteristics. A "term" on a given level has terms (objects, concepts) below it (children), that inherit all the characteristics of their parent, but can be further differentiated by other characteristics.
This is a small part of a mono-axial taxonomy, that is organized around cancer. One can analyze data for just non-invasive breast cancer, all breast cancers, or the top level, cancer.
See multi-axial taxonomy.
One of the benefits of classifying a terminology is that one can analyze the data at any level of the taxonomy.
Term
Designation of a defined concept in a special language by a linguistic expression (ISO 1087). An agreed upon word or words that designate a defined concept.
Terminology
A concept system with designated terms for each concept.
1. The vocabulary of technical terms used in a particular field, subject, science, or art; nomenclature.
2. The study of nomenclature.
A system in which designated words represent a specific concept, usually specific to a discipline.
A representational artifact consisting of representational units which are the general terms of some natural language used to refer to entities in some specific domain.
A set of labels that designate concepts particular to one or more subject fields or domains of human activity. The terms are arrived at through research and analysis of terms in context, for the purpose of documenting and promoting correct usage. (See http://en.wikipedia.org/wiki/Terminology)
Thesaurus
The vocabulary of a controlled indexing language, formerly organized so that a priori (known, assumed, or self-evident) relationships between concepts (e.g. ‘broader’ and ‘narrower’) are made explicit. Examples include Medical Subject Heading (MESH) terms. (ISO 2788)
A controlled vocabulary arranged in a known order.
A system resulting from mapping terms among multiple nursing vocabularies and classification schemes. This was an idea of the past which met its demise when the terminologists could not agree on one terminology for nursing.
Terms from a subject field and their definitions. (ISO 1087).
A set of words known to a person or other entity, or that are part of a specific language. See nomenclature.
Created April 20, 2014
