10 Questions
What is the purpose of having standardized nursing terminologies?
To provide valid clinical care data
What is the primary function of standardized nursing data sets?
To advance the science of nursing practice
Why do standardized nursing terminologies need to permit the measurement of outcomes?
To support evidenced-based decision making
In the context of nursing, what does a 'term' refer to?
A verbal designation of a general concept in a specific subject field
Why is the word 'terminology' used to refer to other terms like 'classification' or 'vocabulary'?
To indicate similar meanings in different contexts
What was one of the criteria identified by Cimino et al. in 1989 for the design of a controlled healthcare vocabulary?
Multiple classifications of terms
Which terminology was NOT recognized by the Council in 1992 as appropriate for nursing practice documentation?
Systematic Nomenclature of Medicine—Clinical Terms (SNOMED-CT)
What is one of the major challenges in the harmonization of nursing and multidisciplinary terminologies?
Overlapping content between terminologies
What is a distinctive feature of existing nursing terminologies according to Rossi Mori et al. (1998)?
Focused on human interpretation
Which data sets were recognized by the Council in 1992 as appropriate for nursing practice documentation?
Nursing Minimum Data Set (NMDS) and The Omaha System
Study Notes
Standardized Nursing Terminology
- A standardized nursing terminology represents the domain of nursing with nursing concepts and includes standardized nursing data that are essential for nursing practice.
- The standardized nursing data sets can be used for analysis and integration with other healthcare disciplines' data, and can serve as research data to advance the science of nursing practice.
Importance of Standardized Nursing Terminology
- Provides valid clinical care data
- Allows data sharing across Health Information Technology (HIT) and Electronic Health Records (EHR) systems
- Supports evidence-based decision making
- Facilitates evaluation of nursing processes
- Permits the measurement of outcomes
Criteria for Standardized Nursing Terminology
- Domain completeness
- Unambiguous terms
- No redundancy
- Synonyms
- Multiple classifications of terms
- Consistency of views
- Explicit relationships
- Other criteria include:
- Free
- Designed for computer-based systems
- Developed from evidence-based practice
Standardized Nursing Terminologies
- NANDA's Classification of Nursing Diagnoses
- Clinical Care Classification (CCC) System (formerly Home Health Care Classification)
- Nursing Intervention Classification (NIC)
- The Omaha System
- Nursing Outcome Classification (NOC)
- Perioperative Nursing Data Set (PNDS)
- International Classification for Nursing Practice (ICNP)
- ABC Codes
- Logical Observation Identifiers Names and Codes (LOINC)
- Systematic Nomenclature of Medicine—Clinical Terms (SNOMED-CT)
- Nursing Minimum Data Set (NMDS)
- Nursing Management Minimum Data Set (NMMDS)
Nursing Terminology Challenges
- Existence of multiple, specialized terminologies with overlapping content, gaps in content, and numerous codes and terms
- Existing terminologies were primarily designed for human interpretation, with computer interpretation as a secondary goal
Test your knowledge on standardized nursing terminology, which consists of essential nursing concepts and data necessary for nursing practice. Explore the importance of standardized nursing data sets in healthcare analysis and integration with other disciplines.
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