Description of BS EN ISO 18104:2014 2014

This International Standard 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

1. analyse the features of different terminologies, including those of other healthcare disciplines, and to establish the nature of the relationship between them,^[3]–[8]

2. develop terminologies for representing nursing diagnoses and nursing actions,^[9]–[12]

3. develop terminologies that are able to be related to each other,^{[3] [8] [13]} and

4. 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 International Standard 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, Annex C provides an introduction to categorial structures to assist those without health informatics expertise to contribute to its development, review, implementation and evaluation.

NOTE 1 Although the scope of testing and review of the first edition of this International 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 and the domain-specific categorial structure for surgical procedures (ISO 1828)^[20] as well as with the WHO ICHI].^[2] The standard may therefore inform development of other general and domain-specific categorial structures in healthcare.

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 A,

• diagnoses made and actions undertaken by nurses working in other professional roles — see Annex B — and

• knowledge relationships such as causal relationships between concepts — see Annex B.

NOTE 2 Throughout the main body of this International Standard, where terms such as nursing diagnosis and nursing action 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.

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