EN ISO 18104-2003 en Health informatics - Categorial structures for representation of nursing diagnoses and nursing actions in terminological systems《医疗信息学 护理用参考术语模式的综合 ISO 18104-2.pdf

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1、BSI Standards PublicationBS EN ISO 18104:2014Health informatics Categorial structures forrepresentation of nursingdiagnoses and nursing actionsin terminological systemsBS EN ISO 18104:2014 BRITISH STANDARDNational forewordThis British Standard is the UK implementation of EN ISO18104:2014. It superse

2、des BS EN ISO 18104:2003 which is withdrawn.The UK participation in its preparation was entrusted to TechnicalCommittee IST/35, Health informatics.A list of organizations represented on this committee can beobtained on request to its secretary.This publication does not purport to include all the nec

3、essaryprovisions of a contract. Users are responsible for its correctapplication. The British Standards Institution 2014. Published by BSI StandardsLimited 2014ISBN 978 0 580 74903 2ICS 35.240.80Compliance with a British Standard cannot confer immunity fromlegal obligations.This British Standard was

4、 published under the authority of theStandards Policy and Strategy Committee on 28 February 2014.Amendments issued since publicationDate Text affectedEUROPEAN STANDARD NORME EUROPENNE EUROPISCHE NORM EN ISO 18104 February 2014 ICS 35.240.80 Supersedes EN ISO 18104:2003English Version Health informat

5、ics - Categorial structures for representation of nursing diagnoses and nursing actions in terminological systems (ISO 18104:2014) Informatique de sant - Structures catgoriques pour la reprsentation des diagnostics de soins et des actions de soins dans les systmes terminologiques (ISO 18104:2014)Med

6、izinische Informatik - Strukturen zur Darstellung von Pflegediagnosen und Pflegeaktionen in terminologischen Systemen (ISO 18104:2014) This European Standard was approved by CEN on 4 January 2014. CEN members are bound to comply with the CEN/CENELEC Internal Regulations which stipulate the condition

7、s for giving this European Standard the status of a national standard without any alteration. Up-to-date lists and bibliographical references concerning such national standards may be obtained on application to the CEN-CENELEC Management Centre or to any CEN member. This European Standard exists in

8、three official versions (English, French, German). A version in any other language made by translation under the responsibility of a CEN member into its own language and notified to the CEN-CENELEC Management Centre has the same status as the official versions. CEN members are the national standards

9、 bodies of Austria, Belgium, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, Former Yugoslav Republic of Macedonia, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, Netherlands, Norway, Poland, Portugal, Romania, Slovakia, Sloveni

10、a, Spain, Sweden, Switzerland, Turkey and United Kingdom. EUROPEAN COMMITTEE FOR STANDARDIZATION COMIT EUROPEN DE NORMALISATION EUROPISCHES KOMITEE FR NORMUNG CEN-CENELEC Management Centre: Avenue Marnix 17, B-1000 Brussels 2014 CEN All rights of exploitation in any form and by any means reserved wo

11、rldwide for CEN national Members. Ref. No. EN ISO 18104:2014 EBS EN ISO 18104:2014EN ISO 18104:2014 (E) 3 Foreword This document (EN ISO 18104:2014) has been prepared by Technical Committee ISO/TC 215 “Health informatics” in collaboration with Technical Committee CEN/TC 251 “Health informatics” the

12、secretariat of which is held by NEN. This European Standard shall be given the status of a national standard, either by publication of an identical text or by endorsement, at the latest by August 2014, and conflicting national standards shall be withdrawn at the latest by August 2014. Attention is d

13、rawn to the possibility that some of the elements of this document may be the subject of patent rights. CEN and/or CENELEC shall not be held responsible for identifying any or all such patent rights. This document supersedes EN ISO 18104:2003. According to the CEN-CENELEC Internal Regulations, the n

14、ational standards organizations of the following countries are bound to implement this European Standard: Austria, Belgium, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, Former Yugoslav Republic of Macedonia, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Latvia,

15、Lithuania, Luxembourg, Malta, Netherlands, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, Switzerland, Turkey and the United Kingdom. Endorsement notice The text of ISO 18104:2014 has been approved by CEN as EN ISO 18104:2014 without any modification. BS EN ISO 18104:2014ISO 1

16、8104:2014(E) ISO 2014 All rights reserved iiiContents PageForeword ivIntroduction v1 Scope . 12 Normative references 23 Terms and definitions . 23.1 General . 23.2 Categories of healthcare entities for nursing diagnoses . 43.3 List of authorized representation relations for nursing diagnoses .53.4 C

17、ategories of healthcare entities for nursing actions 63.5 List of authorized representation relations for nursing actions 74 Categorial structures Conformance principles . 75 Categorial structure for representing nursing diagnoses . 86 Categorial structure for representing nursing actions 9Annex A (

18、informative) Summary of changes to ISO 18104:2003 .11Annex B (informative) Nursing diagnosis and nursing actions in context .17Annex C (informative) Guidance notes for using categorial structures 24Bibliography .28BS EN ISO 18104:2014ISO 18104:2014(E)ForewordISO (the International Organization for S

19、tandardization) is a worldwide federation of national standards bodies (ISO member bodies). The work of preparing International Standards is normally carried out through ISO technical committees. Each member body interested in a subject for which a technical committee has been established has the ri

20、ght to be represented on that committee. International organizations, governmental and non-governmental, in liaison with ISO, also take part in the work. ISO collaborates closely with the International Electrotechnical Commission (IEC) on all matters of electrotechnical standardization.The procedure

21、s used to develop this document and those intended for its further maintenance are described in the ISO/IEC Directives, Part 1. In particular the different approval criteria needed for the different types of ISO documents should be noted. This document was drafted in accordance with the editorial ru

22、les of the ISO/IEC Directives, Part 2. www.iso.org/directivesAttention is drawn to the possibility that some of the elements of this document may be the subject of patent rights. ISO shall not be held responsible for identifying any or all such patent rights. Details of any patent rights identified

23、during the development of the document will be in the Introduction and/or on the ISO list of patent declarations received. www.iso.org/patentsAny trade name used in this document is information given for the convenience of users and does not constitute an endorsement.For an explanation on the meanin

24、g of ISO specific terms and expressions related to conformity assessment, as well as information about ISOs adherence to the WTO principles in the Technical Barriers to Trade (TBT) see the following URL: Foreword - Supplementary informationThe committee responsible for this document is ISO/TC 215, H

25、ealth informatics.This second edition cancels and replaces the first edition (ISO 18104:2003), which has been technically revised. For the history of the revision and a summary of the changes, see the Introduction and Annex A.iv ISO 2014 All rights reservedBS EN ISO 18104:2014ISO 18104:2014(E)Introd

26、uctionDevelopment of terminological systems (also referred to as terminologies) to support nursing has been motivated by multiple factors including the need to describe nursing in order to educate and inform students and others, represent nursing concepts in electronic systems and communications, in

27、cluding systems that support multiprofessional team communications and personal health records, and analyse data about the nursing contribution to patient care and outcomes for quality improvement, research, management, reimbursement, policy and other purposes.Multiple terminologies exist to support

28、 representation of concepts for healthcare purposes; some of these are relevant to the nursing domain. In the context of health informatics, there is a clear requirement for both domain coverage and for interoperability among computer-processable terminological systems that support nursing. Nursing

29、terminologies, or those parts of healthcare-related terminologies that are relevant to nursing, include concept representations for nursing diagnoses and nursing actions.A nursing diagnosis is a label assigned to an assessment finding, event, situation or other health issue to indicate that it is co

30、nsidered to be noteworthy by the nurse and, where possible, the subject of care. Nursing actions are acts performed by or under the direction of a nurse, with the intention of directly or indirectly improving or maintaining the health of a person, group or population, the precise scope of nursing ac

31、tions being delineated in each jurisdiction. These concepts and the scope of nursing practice are further elaborated in Annex B.The first edition of this International Standard1focused on the conceptual structures that are the basis of nursing terminologies in order to support interoperability. A ma

32、jor purpose was “to establish a nursing reference terminology model consistent with the goals and objectives of other specific health terminology models in order to provide a more unified reference health model”. This purpose is still relevant to this revision of the standard, to support interdiscip

33、linary communication, for example, where single, shared records are used, including records held by patients.Following ISO rules, a review of ISO 18104:2003 was undertaken during 2008/09; ISO national member bodies, nursing organisations, industry representatives and experts provided comment. In add

34、ition to evaluation of the purpose, target groups, definitions and provisions of the standard, the review considered the implications of relevant International Standards published since 2003. The main findings/recommendations of the review were as follows.a) The standard was being used in at least 1

35、1 member countries and by several international terminology development organizations.b) Any revision should be based on a clearly articulated value proposition supported by evidence from the review. Published examples of use and value are provided in the Bibliography, linked to the specific purpose

36、s stated in Clause 1. There is anecdotal evidence of other uses, including supporting design of terminology content in electronic record systems.c) Normative references and definitions to be updated. Other relevant international work needed to be considered, such as the World Health Organization Fam

37、ily of International Classifications (WHO-FIC) International Classification of Healthcare Interventions (ICHI).2d) A review of relevant International Standards confirmed that the naming of some categories might need to be revised and that some categories could have been more appropriately designated

38、 as semantic links.e) Responses indicated that “dimension” and “potentiality” in the diagnosis model and “target” in the action model were not applied reliably by different users and required further consideration. ISO 2014 All rights reserved vBS EN ISO 18104:2014ISO 18104:2014(E)f) It was recommen

39、ded that a model for outcomes be considered and that informative annexes clarify the relationship between the model for diagnoses and the model for actions, as well as points of intersection between terminology models and information models.g) A number of reviewers recommended that the standard be s

40、upported by implementation guidance/examples, and that the title and the language used be revised, so that it would be better understood by target groups.This second edition addresses these findings and recommendations. In the main body of the standard, two redundant categories have been removed (di

41、mension and recipient of care) and changes have been made to correct errors, clarify meaning and update definitions. Annex A summarizes the changes. The standard defines the structure of terminological expressions for nursing diagnoses and nursing actions; the professional meaning of these construct

42、s and their relationship to other record components is addressed in Annex B along with points of intersection between terminology models and information models. An informative description of categorial structures and their implementation is provided by Annex C.vi ISO 2014 All rights reservedBS EN IS

43、O 18104:2014INTERNATIONAL STANDARD ISO 18104:2014(E)Health informatics Categorial structures for representation of nursing diagnoses and nursing actions in terminological systems1 ScopeThis International Standard specifies the characteristics of two categorial structures, with the overall aim of sup

44、porting 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 toa) analyse the feat

45、ures of different terminologies, including those of other healthcare disciplines, and to establish the nature of the relationship between them,38b) develop terminologies for representing nursing diagnoses and nursing actions,912c) develop terminologies that are able to be related to each other,3 8 1

46、3andd) establish relationships between terminology models, information models and ontologies in the nursing domain.1416There is early evidence that the categorial structures can be used as a framework for analysing nursing practice17and for developing nursing content of electronic record systems.18

47、19This 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 ove

48、rlap 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; developer

49、s 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, implementati