Interpretation of an international terminology standard in the development of a logic-based compositional terminology

Purpose: Version 1.0 of the International Classification for Nursing Practice (ICNP®) is a logic-based compositional terminology. International Organization for Standardization (ISO) 18104:2003 Health Informatics¿Integration of a reference terminology model for nursing is an international standard to support the development, testing and implementation of nursing terminologies. Methods: This study examines how ISO 18104:2003 has been interpreted in the development of ICNP® Version 1.0 by identifying mappings between ICNP® and the ISO standard. Representations of diagnostic and interventional statements within ICNP® are also analyzed according to the requirements mandated by the ISO standard. Results: All structural components of ISO 18104:2003 i.e. semantic categories, semantic domains, qualifiers and semantic links are represented either directly or in interpreted form within ICNP®. The formal representations within ICNP® of diagnostic and interventional statements meet the requirement of the ISO standard. Conclusions: The findings of this study demonstrate that ICNP® Version 1.0 conforms to ISO 18104:2003. More importantly perhaps, this study provides practical examples of how components of a terminology standard might be interpreted and it examines how such a standard might be used to support the definition of high-level schemata in developing logic-based compositional terminologies

Categorical structure analysis of ISO 18104 standard in nursing documentation

OBJECTIVE: To verify whether categorical structure of the ISO 18104 standard is adequate to support electronic documentation of nursing actions and nursing diagnoses and to facilitate the development of nursing diagnoses and nursing actions expressions. METHODS: A cross-sectional design with two use cases in electronic records from two teaching hospitals that employ different nursing terminologies. RESULT: Case A included 40 diagnostic expressions and 97 interventions. All records for nursing diagnoses included focus, judgment, or clinical finding. All interventions were recorded using action verbs and targets. Few other qualifiers were used. Case B provided two diagnoses and 371 expressions for nursing actions. Diagnoses included focus and judgment. All interventions, except one, were documented using action verbs and targets. CONCLUSION: ISO 18104 was adequate to support documentation of nursing actions and diagnoses expressions.OBJETIVO: Verificar se a estrutura categorial da Norma ISO 18104 é adequada para apoiar a documentação eletrônica de diagnósticos e ações de enfermagem e auxiliar na formação de expressões diagnósticas e ações de enfermagem. MÉTODOS: Desenho transversal com dois casos de uso nos registros eletrônicos de dois hospitais universitários que utilizam diferentes terminologias de Enfermagem. RESULTADO: O caso de uso A forneceu 40 expressões diagnósticas e 97 intervenções. Todos os registros para diagnósticos de enfermagem continham foco, julgamento ou achado clínico. As intervenções foram registradas usando verbo de ação e alvo. Os demais qualificadores foram pouco empregados. O caso de uso B forneceu dois diagnósticos e 371 expressões para ações de enfermagem. Os diagnósticos possuíam foco e julgamento. Todas as intervenções, exceto uma, foram documentadas usando verbos de ação e alvo. CONCLUSÃO: A Norma ISO18104 mostrou-se adequada para apoiar a documentação de expressões diagnósticas e de ação de enfermagem.Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)Universidade Federal de São Paulo (UNIFESP) Escola Paulista de EnfermagemUniversidade de São Paulo Escola de EnfermagemUniversidade Federal de Santa CatarinaUNIFESP, EPESciEL

A norma ISO 18.104: 2003 como modelo integrador de terminologias de enfermagem

This paper presents the ISO 18.104:2003 as an integrative model of nursing terminology. It describes the standard, studies and experiences with its use and discusses possibilities to develop knowledge in the field. The standard has been shown to be effective in developing reference terminologies, and as a standard method for interoperability and reuse. Studies have internal limitations such as language and notations unknown to nursing. Correspondence of the model with classifications used in health services and practice is incipient, which hinders its applicability and development due to the lack of examples to be analyzed and discussed.Este estudio tiene como objetivo presentar la ISO 18.104:2003 como modelo integrador de terminologías de enfermería; él describe la norma, investigaciones y experiencias de su uso y discute las posibilidades del desarrollo de conocimiento en el área. La norma se muestra efectiva para la composición de terminologías de referencia y como método estándar para la interoperabilidad y uso. Se verificó que las investigaciones poseen limitaciones internas, como lenguaje y notaciones desconocidas por la enfermería. Es incipiente la correspondencia del modelo con las clasificaciones utilizadas en los servicios y en la práctica, lo que impide su análisis. Se considera que hay poca correspondencia del modelo con las clasificaciones utilizadas en los servicios y en la práctica profesional, lo que impide su aplicabilidad y su evolución, por la ausencia de ejemplos a ser analizados y discutidos.Este estudo teve como objetivo apresentar a ISO 18.104:2003 como modelo integrador de terminologias de enfermagem, descrevendo a norma, pesquisas e experiências de seu uso e discutindo as possibilidades de desenvolvimento do conhecimento na área. A norma se mostra efetiva para a composição de terminologias de referência e como método padrão para a interoperabilidade e reuso. Verificou-se que as pesquisas possuem limitações internas, como linguagem e notações desconhecidas pela enfermagem. É incipiente a correspondência do modelo às classificações utilizadas nos serviços e na prática, o que impede sua análise. Considera-se que há pouca correspondência do modelo às classificações utilizadas nos serviços e na prática profissional, impedindo sua aplicabilidade e evolução, pela ausência de exemplos a serem analisados e discutidos

Applicability of the ISO Reference Terminology Model for Nursing to the Detailed Clinical Models of Perinatal Care Nursing Assessments

Objectives: The purpose of this study was to examine the applicability of the International Organization for Standardization (ISO) reference terminology model for nursing to describe the terminological value domain content regarding the entities and attributes of the detailed clinical models (DCMs) used for nursing assessments. Methods: The first author mapped 52 DCM entities and 45 DCM attributes used for perinatal care nursing assessments to semantic domains and their qualifiers to the ISO model. The mapping results of the entity and attribute concepts were classified into four categories: mapped to a semantic domain qualifier, mapped to a semantic domain, mapped to a broader semantic domain concept, and not mapped. The DCM mapping results were classified into three categories: fully mapped, partially mapped, and not mapped. The second author verified the mapping. Results: All of the entities and 53.3 % of the attribute concepts of the DCMs were mapped to semantic domains or semantic domain qualifiers of the ISO model, 37.8 % of the attributes were mapped to the broader semantic domain concept, and 8.9 % of the attributes were not mapped. At the model level, 48.1 % of the DCMs were fully mapped to semantic domains or semantic domain qualifiers of the ISO model, and 51.9 % of the DCMs were partially mapped. Conclusions: The findings of this study demonstrate that the ISO reference terminology model for nursing is applicable in representing the DCM structure for perinatal care nursing assessment. However, more qualifiers of the Judgment semantic domain are required in orde

The development of a nursing subset of patient problems to support interoperability

Since the emergence of electronic health records, nursing information is increasingly being recorded and stored digitally. Several studies have shown that a wide range of nursing information is not interoperable and cannot be re-used in different health contexts. Difficulties arise when nurses share information with others involved in the delivery of nursing care. The aim of this study is to develop a nursing subset of patient problems that are prevalent in nursing practice, based on the SNOMED CT terminology to assist in the exchange and comparability of nursing information. Explorative qualitative focus groups were used to collect data. Mixed focus groups were defined. Additionally, a nursing researcher and a nursing expert with knowledge of terminologies and a terminologist participated in each focus group. The participants, who work in a range of practical contexts, discussed and reviewed patient problems from various perspectives. Sixty-seven participants divided over seven focus groups selected and defined 119 patient problems. Each patient problem could be documented and coded with a current status or an at-risk status. Sixty-six percent of the patient problems included are covered by the definitions established by the International Classification of Nursing Practice, the reference terminology for nursing practice. For the remainder, definitions from either an official national guideline or a classification were used. Each of the 119 patient problems has a unique SNOMED CT identifier. To support the interoperability of nursing information, a national nursing subset of patient problems based on a terminology (SNOMED CT) has been developed. Using unambiguously defined patient problems is beneficial for clinical nursing practice, because nurses can then compare and exchange information from different settings. A key strength of this study is that nurses were extensively involved in the development process. Further research is required to link or associate nursing patient problems to concepts from a nursing classification with the same meaning