NF EN ISO 18104
Health Informatics - Categorial structures for representation of nursing diagnoses and nursing actions in terminological systems
ISO 18104:2014 specifies the characteristics of two categorial structures, with the overall aim of supporting interoperability in the exchange of meaningful information between information systems in respect of nursing diagnoses and nursing actions. Categorial structures for nursing diagnoses and nursing actions support interoperability by providing common frameworks with which to analyse the features of different terminologies, including those of other healthcare disciplines, and to establish the nature of the relationship between them, develop terminologies for representing nursing diagnoses and nursing actions, develop terminologies that are able to be related to each other, and establish relationships between terminology models, information models and ontologies in the nursing domain.It is applicable to the following user groups: developers of terminologies that include nursing diagnosis and nursing action concepts; developers of categorial structures and terminologies for other healthcare domains, to support clarification of any relationship to or overlap with nursing concepts; developers of models for health information management systems such as electronic health records and decision support systems, to describe the expected content of terminological value domains for particular attributes and data elements in the information models; developers of information systems that require an explicit system of concepts for internal organization, data warehouse management or middleware services; developers of software for natural language processing, to facilitate harmonization of their output with coding systems.It is not intended for use by clinical nurses without health informatics expertise. However, it provides an introduction to categorial structures to assist those without health informatics expertise to contribute to its development, review, implementation and evaluation.Topics considered outside the scope of ISO 18104:2014 include complete categorial structures that would cover all the potential details that could appear in expressions of nursing diagnoses and nursing actions, a detailed terminology of nursing diagnoses or nursing actions, a "state model" for diagnoses or actions ? for example, provisional diagnosis or absent diagnosis, planned action or action not to be done ? diagnoses made and actions undertaken by nurses working in other professional roles, and knowledge relationships such as causal relationships between concepts.
ISO 18104:2014 specifies the characteristics of two categorial structures, with the overall aim of supporting interoperability in the exchange of meaningful information between information systems in respect of nursing diagnoses and nursing actions. Categorial structures for nursing diagnoses and nursing actions support interoperability by providing common frameworks with which to analyse the features of different terminologies, including those of other healthcare disciplines, and to establish the nature of the relationship between them, develop terminologies for representing nursing diagnoses and nursing actions, develop terminologies that are able to be related to each other, and establish relationships between terminology models, information models and ontologies in the nursing domain.
It is applicable to the following user groups: developers of terminologies that include nursing diagnosis and nursing action concepts; developers of categorial structures and terminologies for other healthcare domains, to support clarification of any relationship to or overlap with nursing concepts; developers of models for health information management systems such as electronic health records and decision support systems, to describe the expected content of terminological value domains for particular attributes and data elements in the information models; developers of information systems that require an explicit system of concepts for internal organization, data warehouse management or middleware services; developers of software for natural language processing, to facilitate harmonization of their output with coding systems.
It is not intended for use by clinical nurses without health informatics expertise. However, it provides an introduction to categorial structures to assist those without health informatics expertise to contribute to its development, review, implementation and evaluation.
Topics considered outside the scope of ISO 18104:2014 include complete categorial structures that would cover all the potential details that could appear in expressions of nursing diagnoses and nursing actions, a detailed terminology of nursing diagnoses or nursing actions, a "state model" for diagnoses or actions ? for example, provisional diagnosis or absent diagnosis, planned action or action not to be done ? diagnoses made and actions undertaken by nurses working in other professional roles, and knowledge relationships such as causal relationships between concepts.
The purpose of ISO 18104:2003 is to establish a nursing reference terminology model consistent with the goals and objectives of other specific health terminology models in order to provide a more unified reference health model. This International Standard includes the development of reference terminology models for nursing diagnoses and nursing actions and relevant terminology and definitions for its implementation. The potential uses for this reference terminology model are to support the intensional definition of nursing diagnosis and nursing action concepts reflective of a broad range of roles and practice settings,facilitate the representation of nursing diagnosis and nursing action concepts and their relationships in a manner suitable for computer processing,provide a framework for the generation of compositional expressions from atomic concepts within a reference terminology,facilitate the construction of nursing terminologies in a regular form which will make mapping among them easier,facilitate the mapping among nursing diagnosis and nursing action concepts from various terminologies including those developed as interface terminologies and statistical classifications,enable the systematic evaluation of terminologies and associated terminology models for purposes of harmonization, andprovide a language to describe the structure of nursing diagnosis and nursing action concepts in order to enable appropriate integration with other reference terminology models and with information models.
This document specifies the characteristics of categorial structures, representing nursing practice. The overall aim of this document is to support interoperability in the exchange of meaningful information between information systems in respect of nursing diagnoses, nursing actions and nurse sensitive outcomes. Categorial structures for nursing diagnoses, nursing actions, nurse sensitive outcomes and associated categories support interoperability by providing common frameworks with which to a) analyse the features of different terminologies, including pre- and post-coordinated expressions, those of other healthcare disciplines, and to establish the nature of the relationship between them,[3][4][5][6][7][8] b) develop terminologies for representing nursing diagnoses, nursing actions,[9][10][11][12] and nurse sensitive outcomes, c) develop terminologies that are able to be related to each other,[3][8][13] and d) establish relationships between terminology models, information models, including archetypes, and ontologies in the nursing domain.[14][15][16][45] There is early evidence that the categorial structures can be used as a framework for analysing nursing practice,[17] for developing nursing content of electronic record systems,[18][19] document the value of nursing services provided and to make nursing’s contribution visible[16][36][47][50].
- Avant-proposiv
- Introductionv
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1 Domaine d'application1
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2 Références normatives2
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3 Termes et définitions2
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4 Structures catégorielles: principes de conformité8
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5 Structure catégorielle destinée à la représentation des diagnostics infirmiers9
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6 Structure catégorielle destinée à la représentation des actions infirmières10
- Annexe A (informative) Résumé des modifications apportées à l'ISO 18104:200311
- Annexe B (informative) Le diagnostic infirmier et les actions infirmières en contexte18
- Annexe C (informative) Notes d'orientation concernant l'utilisation des structures catégorielles.25
- Bibliographie29
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