scope:

This document specifies the characteristics of three categorial structures, representing nursing practice with the overall aim of supporting 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 and nurse sensitive outcomes support interoperability by providing common frameworks with which to: a) analyse the features of different terminologies, including those of other healthcare disciplines, and to establish the nature of the relationship between them[3]-[8], b) develop terminologies for representing nursing diagnoses, nursing actions[9]-[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 and ontologies in the nursing domain[14]-[16]. There is early evidence that the categorial structures can be used as a framework for analysing nursing practice[17] and for developing nursing content of electronic record systems[18][19]. This document is applicable to the following user groups: - developers of terminologies that include nursing diagnosis, nursing action and nurse sensitive outcome concepts; - developers of categorial structures and terminologies for other healthcare domains, to support clarification of a 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 sub-categories and data elements in the information models; - developers of information systems that require an explicit system of concepts for internal organization, data repository management or middleware services; - developers of software for natural language processing, to facilitate harmonization of their output with coding systems.