Nursing

Desired Organizational Criteria for Core Terminologies 1. Establish intellectual property and licensing terms for the core terminologies (perhaps as a group) that allow the widest use while preventing the proliferation of local, non-standard “dialects.” 2. Provide the governance structure of the core terminology developers (perhaps as a group) that guarantees responsible stewardship of the standard […]

Nine Desired Technical Criteria 1. Comprehensive Domain Coverage: The terminology includes most of the concepts and terms needed for primary clinical documentation in the defined domain area. 2. Meaningless Identifiers: The unique codes used to identify concepts in the terminology are unrelated to the meaning of the concepts or their locations in the concept hierarchy.

Four Essential Technical Criteria 1. Concept Orientation: Elements of the terminology are coded concepts, with possible multiple synonymous text representations, and hierarchical or definitional relationships to other coded concepts. 2. Concept Permanence: The meaning of each code concept in a terminology remains forever unchanged. If the definition of a concept needs to be changed or

Incomplete Electronic Documentation of Nursing Care Identifying Challenges and Opportunities within Standard Nursing Terminologies 26 VIII. Conclusion In addressing the need to capture nursing data, Welton and Harper (2016) stated, “…as we move toward a value- oriented health care system, there is a growing need to address the largest human capital component of the system,

Resource-Intensive Mapping Requirements, Curation and Maintenance Identifying Challenges and Opportunities within Standard Nursing Terminologies 25 needed training and skills in terminology and mapping techniques are in short supply throughout the market. Further, expert terminologists may not always perform their mappings in exactly the same way, creating an issue with interoperability while imprecise mapping creates issues

Nursing Management Minimum Data Set (NMMDS) NMMDS Latest Update via UMLS Not in UMLS Original Publication 1996/1997 The NMMDS is a uniform minimum health data set that “specifically identifies variables essential to nursing administrators for decision-making about nursing care effectiveness” (Gardner-Huber, Delaney, Crossley, Mehmert, & Ellerbe). It was developed to provide a framework for the

Nursing Minimum Data Set (NMDS) NMDS Latest Update via UMLS NMDS- Not in UMLS Original Publication NMDS- 1983 The NMDS is a set of elements developed consistent with the general concept of a Uniform Minimum Health Data Set (UMHDS) and specifically intended for the collection of essential nursing care data. Under the leadership of Harriet

Alternative Billing Concepts (ABC) Codes ABC Codes Latest version of terminology standard available through UMLS 2009 Original Publication 2000 ABC Codes do not include an implicit information model and were designed for computerized documentation and measurement of non-physician and alternative medicine health services. They allow health care disciplines not reimbursed using standard billing codes to

Perioperative Nursing Data Set (PNDS) PNDS Latest Update via UMLS 2011 Original Publication 1999 Created in 1993, PNDS is maintained by the Association of periOperative Registered Nurses (AORN) Board of Directors (Taulman & Latz, 2011). PNDS is a “standardized language that addresses the perioperative patient experience from pre-admission until discharge; and describes the nursing diagnoses,

Omaha System Omaha System Latest Update via UMLS 2005 Original Publication 1975 The Omaha System includes terminology and an implicit information model. In the 1970s, the Visiting Nurse Association (VNS) of Omaha revised its home health and public health client records to adopt a problem-oriented approach. This new approach, with the goal of providing a