BS EN ISO 18104-2014 Health informatics Categorial structures for representation of nursing diagnoses and nursing actions in terminological systems《医疗信息 护理用参考术语模式的综合》.pdf

1、BSI Standards PublicationBS EN ISO 18104:2014Health informatics Categorial structures forrepresentation of nursingdiagnoses and nursing actionsin terminological systemsCopyright British Standards Institution Provided by IHS under license with BSI - Uncontrolled Copy Not for ResaleNo reproduction or

2、networking permitted without license from IHS-,-,-BS EN ISO 18104:2014 BRITISH STANDARDNational forewordThis British Standard is the UK implementation of EN ISO18104:2014. It supersedes BS EN ISO 18104:2003 which is withdrawn.The UK participation in its preparation was entrusted to TechnicalCommitte

3、e 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 necessaryprovisions of a contract. Users are responsible for its correctapplication. The British Standards Institution 20

4、14. 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 published under the authority of theStandards Policy and Strategy Committee on 28 February 2014.Amendments issued sin

5、ce publicationDate Text affectedCopyright British Standards Institution Provided by IHS under license with BSI - Uncontrolled Copy Not for ResaleNo reproduction or networking permitted without license from IHS-,-,-EUROPEAN STANDARD NORME EUROPENNE EUROPISCHE NORM EN ISO 18104 February 2014 ICS 35.24

6、0.80 Supersedes EN ISO 18104:2003English Version Health informatics - 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 actio

7、ns de soins dans les systmes terminologiques (ISO 18104:2014)Medizinische 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 th

8、e CEN/CENELEC Internal Regulations which stipulate the conditions 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 Managemen

9、t Centre or to any CEN member. This European Standard exists in 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

10、as the official versions. CEN members are the national standards 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, N

11、etherlands, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, 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

12、 rights of exploitation in any form and by any means reserved worldwide for CEN national Members. Ref. No. EN ISO 18104:2014 ECopyright British Standards Institution Provided by IHS under license with BSI - Uncontrolled Copy Not for ResaleNo reproduction or networking permitted without license from

13、IHS-,-,-BS 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 secretariat of which is held by NEN. This European Sta

14、ndard 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 drawn to the possibility that some of the elements of t

15、his 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 national standards organizations of the following count

16、ries 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, Lithuania, Luxembourg, Malta, Netherlands, Norway, Pol

17、and, 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. Copyright British Standards Institution Provided by IHS under license with BSI

18、- Uncontrolled Copy Not for ResaleNo reproduction or networking permitted without license from IHS-,-,-BS EN ISO 18104:2014ISO 18104:2014(E) ISO 2014 All rights reserved iiiContents PageForeword ivIntroduction v1 Scope . 12 Normative references 23 Terms and definitions . 23.1 General . 23.2 Categori

19、es of healthcare entities for nursing diagnoses . 43.3 List of authorized representation relations for nursing diagnoses .53.4 Categories of healthcare entities for nursing actions 63.5 List of authorized representation relations for nursing actions 74 Categorial structures Conformance principles .

20、75 Categorial structure for representing nursing diagnoses . 86 Categorial structure for representing nursing actions 9Annex A (informative) Summary of changes to ISO 18104:2003 .11Annex B (informative) Nursing diagnosis and nursing actions in context .17Annex C (informative) Guidance notes for usin

21、g categorial structures 24Bibliography .28Copyright British Standards Institution Provided by IHS under license with BSI - Uncontrolled Copy Not for ResaleNo reproduction or networking permitted without license from IHS-,-,-BS EN ISO 18104:2014ISO 18104:2014(E)ForewordISO (the International Organiza

22、tion for Standardization) 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

23、has the right 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

24、 procedures 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 ed

25、itorial rules 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 i

26、dentified 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

27、the meaning 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

28、/TC 215, Health 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 reservedCopyright British Standards Insti

29、tution Provided by IHS under license with BSI - Uncontrolled Copy Not for ResaleNo reproduction or networking permitted without license from IHS-,-,-BS EN ISO 18104:2014ISO 18104:2014(E)IntroductionDevelopment of terminological systems (also referred to as terminologies) to support nursing has been

30、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, including systems that support multiprofessional team communications and personal health records, and analyse

31、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 representation of concepts for healthcare purposes; some of these are relevant to the nursing domain. In th

32、e 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 terminologies, or those parts of healthcare-related terminologies that are relevant to nursing, include conc

33、ept 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 considered to be noteworthy by the nurse and, where possible, the subject of care. Nursing actions are acts pe

34、rformed 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 actions being delineated in each jurisdiction. These concepts and the scope of nursing practice are further el

35、aborated 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 major purpose was “to establish a nursing reference terminology model consistent with the goals and objectives

36、 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 interdisciplinary communication, for example, where single, shared records are used, including records held by patients

37、.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 addition to evaluation of the purpose, target groups, definitions and provisions of the standard, the review co

38、nsidered 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 11 member countries and by several international terminology development organizations.b) Any revision should

39、 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 purposes stated in Clause 1. There is anecdotal evidence of other uses, including supporting design of terminology

40、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 Family of International Classifications (WHO-FIC) International Classification of Healthcare Interventions (ICH

41、I).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 as semantic links.e) Responses indicated that “dimension” and “potentiality” in the diagnosis model and “ta

42、rget” in the action model were not applied reliably by different users and required further consideration. ISO 2014 All rights reserved vCopyright British Standards Institution Provided by IHS under license with BSI - Uncontrolled Copy Not for ResaleNo reproduction or networking permitted without li

43、cense from IHS-,-,-BS EN ISO 18104:2014ISO 18104:2014(E)f) It was recommended 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 info

44、rmation models.g) A number of reviewers recommended that the standard be supported 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

45、 main body of the standard, two redundant categories have been removed (dimension 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

46、diagnoses and nursing actions; the professional meaning of these constructs 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 imp

47、lementation is provided by Annex C.vi ISO 2014 All rights reservedCopyright British Standards Institution Provided by IHS under license with BSI - Uncontrolled Copy Not for ResaleNo reproduction or networking permitted without license from IHS-,-,-BS EN ISO 18104:2014INTERNATIONAL STANDARD ISO 18104

48、: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 supporting interoperability in the exchange of

49、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 features of different terminologies, including those of other healthcare