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Ivan cliff


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Ivan cliff

  1. 1. ANA Recognized Terminologies<br />Nursing data at present is too often confined to a paper record and used only for individual patient care. It is never included in data that is submitted by health care agencies to governments and other regulating entities for use in health care planning. This creates a situation in which nursing's contribution to health care is invisible. If nursing data is to be included in submitted data it is imperative that it be computerized. Computerizing the data requires the solution to two problems:<br />ProblemSolutionWhat data should be included?Minimum Data SetsWhat terms will be used to designate this data?Standardized Terminologies<br />Technically, the term, data set, means "... a collection of data elements organized for a specific purpose." Under this definition, the term can include both minimum data sets and standardized terminologies. In these pages, the term data set will be used to mean the designation of data categories (elements) with unambiguous definitions, for example "nursing diagnosis," and standardized terminology will mean a collection of agreed upon terminology for concepts such as "decreased cardiac output."<br /> Confusion arises, however, because some collections called data sets also contain a standardized terminology. In nursing, the nursing specific standardized terminologies are designed to capture the nursing care elements in the Nursing Minimum Data Set (NMDS<br />Standardized terminologies permit several operations. One, the use of data in an aggregated(the same data for many patients) format to determine outcomes and to plan regional, state, national, and international levels for health care, and two, the ability to find information (literature or clinical records) about a given term.<br />Minimum Data Sets<br />The United States Health Information Policy Council defines a minimum data set as the "minimum set of items of information with uniform definitions and categories, concerning a specific aspect or dimension of the health care system which meets the essential needs of multiple data users." Thus, the minimum data required depends on the circumstances. Meeting the needs of care givers requires data that is different than the data required by those who make policy. The first requires detailed information, the second data that has been summarized.<br />To overcome this deficiency, a Nursing Minimum Data Set (NMDS) was conceived in the 1970s and birthed in the 1980's. Unfortunately, it is too often confused with other minimum data sets.<br />In a minimum data set, the definitions of each element need to be clear and unambiguous. The current U.S. Nursing Minimum Data Set contains only the names and definitions for the elements, not the terminology used as data for each element. For example, in the NMDS nursing diagnosis is defined as "A clinical judgment made by a nurse about a human response to an actual or potential health problem, the intervention for which nurses are accountable.<br />The terminology used to represent a nursing diagnosis is NOT defined by the US Nursing Minimum Data Set (NMDS). The standardized terminology from the North American Nursing Diagnoses Association International (NANDA) is one of the American Nurses Association (ANA) recognized standard nursing terminologies that can be used to collect the nursing diagnosis element in the NMDS.<br />Standardized Terminologies<br />Very simply a standardized terminology is a list of terms with agreed upon definitions so that when a term is used it means the same thing to everyone. Often the terms are organized into a taxonomy (See page 291) so that data from various categories can be aggregated. For example, in NANDA all terms that belong to the overall category of "Infection" could be looked at as a whole. Going further up the taxonomy, all the terms from any category in the "Safety/Protection" category, of which infection is one, can be further aggregated. This type of arrangement makes it easy to look at parts, but also the whole. Usually when the terms are aggregated, data other than just the nursing diagnosis will be included. For example, one might combine a specific medical diagnosis with nursing diagnoses from either a specific nursing diagnosis, or any of the categories above it in the taxonomy.<br />Some terminologies are what are called multi-axial.<br />Whether a set of standardized terminologies is officially termed a vocabulary, a taxonomy, combinatorial vocabulary, or formal language is not important for our purposes here. In presenting this summary of the standardized terminologies the term standardized nursing terminology will be used to represent all of the standardized terminologies recognized by the ANA.<br />ANA Recognized Minimum Data Sets<br />Nursing Minimum Data Set (NMDS) (1999)<br />Nursing Management Minimum Data Set (NMMDS) (2003)<br /> <br />ANA Recognized Standardized Terminologies That Support Nursing Practice<br /><ul><li>Omaha System (1992), CCC (Clinical Care Classification - Formerly the HHCC Home Health Care Classification) (1992) and LOINC - Logical Observation Identifiers Names & Codes (2002)</li></ul>** These two languages can be used "as is" without payment of royalties. Users, however, are not authorized to alter or modify them.<br /><ul><li>SNOMED-CT (1999) Systematized Nomenclature of Medicine. SNOMED-CT received recognition from the ANA in 2003.</li></ul>**allows mapping to the nursing problems (diagnoses) for NANDA II, the Omaha system, HHCC, and the PNDS. Interventions for NIC, Omaha, HHCC, and PNDS and outcomes for NOC, and the PNDS.<br /><ul><li>ICNP International Classification for Nursing Practice (2000)</li></ul>**This language is copyrighted. Written permission from the International Council of Nurses is required, but no fee is required for non-commercial use. A small fee is charged for-profit use. It is currently being mapped to SNOMED-CT.<br /><ul><li>Alternative Link</li></ul>** support electronic and paper claims processing and fee structures for providers, health care payers, managed care organizations and affiliate organizations. Although ANA recognized, it has a purpose different than the others.<br />5. NANDA-I (North American Nursing Diagnosis Association International)<br />6. NIC (Nursing Interventions Classification) (1992)<br />7. NOC (Nursing Outcomes Classification (1997)<br />