scope:

Main purpose

This International Standard specifies the characteristics of two categorial structures (4.2), and the minimal domain constraints (4.5) required for conformance, 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 (4.2) for nursing diagnoses and nursing actions support interoperability by providing common frameworks with which to:

a) analyse the features of different terminologies and to establish the nature of the relationship between them [3] - [8];

b) develop terminologies for representing nursing diagnoses and nursing actions [9] - [12];

c) develop terminologies that are able to be related to each other [3], [8], [13];

d) establish relationships between terminology models, information models and ontologies in the nursing domain [14] - [16];

There is early evidence that the categorial structure for nursing actions can be used as a framework for analyzing nursing practice [17] and for developing content of electronic nursing summaries [18].

Target audience

This Standard is applicable to:

• 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 harmonisation of their output with coding systems.

The Standard is not intended for use by clinical nurses without health informatics expertise. However, Annex D provides an introduction to categorial structures to assist those without health informatics expertise to contribute to its development, review, implementation and evaluation.

Although the scope of testing and review of the Standard has been limited to nursing, the two categorial structures have features in common with the more general framework for clinical findings (ISO TS 22789:2010) and the domain-specific categorial structure for surgical procedures (EN 1828:2008) as well as with the WHO ICHI [2]. It may therefore inform development of other general and domain-specific categorial structures in health care.

Out of scope

Topics considered outside the scope of this International Standard 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 - see Annex B.3.3

• knowledge relationships such as causal relationships between concepts - see Annex C.1.3.

Note that, throughout the Normative part of the IS, where the terms nursing diagnosis, nursing action etc are used, these refer to representation of these concepts in electronic systems, not to the professional activity of making a diagnosis or performing an action.