Nursing

Domain Title & Team Lead:Nursing: Alicia Bradford, CMSScope:Consolidated Health Informatics InitiativeFinal Recommendation Information Sheet 1This domain is defined as a terminology that is used to identify, classify, and name thedelivery of nursing care. Sub-domains are derived from the Nursing Process andAmerican Nurses Association (ANA) approved Nursing Minimum Data Set (NMDS),emphasizing nursing assessment, diagnosis, interventions, and outcomes of nursing care.Domain/Sub-domainIn-Scope (Y/N)Assessment / ObservationsYPlan / GoalsYDiagnosisYInterventionsYEvaluation / OutcomeYIntensity of Nursing Care N*Patient Demographics N**Intensity of nursing care, part of the NMDS, is out of scope as no rating orvocabulary standard exists or is widely implemented. Patient demographic data isout of scope and being covered by the demographics workgroup.Alternatives Identified1. SNOMED CT2. ABC Codes3. NANDA (The North American Nursing Diagnosis Association)4. NIC (Nursing Interventions Classification)5. NOC (Nursing Outcomes Classification)6. Omaha System7. HHCC (Home Health Care Classification)8. PCDS (Patient Care Data Set)9. PNDS (Perioperative Nursing Data Set)10. ICNP (International Classification for Nursing Practice)11. Clinical LOINC (Logical Observation Identifiers Names & Codes)1 Information Sheet designed specifically to facilitate communication between CHI and NCVHSSubcommittee on Standards and Security resulting from May 20, 2003 testimony. CHI may seek assistanceto help further define scope, alternatives to be considered and/or issues to be included in evaluationprocess.

Procedure by IntentTherapeutic ProcedureMedical TherapiesPain ManagementPain ControlAcquisition:An in-principal agreement has been reached that provides, in the US, SNOMED CT asone of the Category 0 codesets, essentially allowing free distribution and use in the US.Conditions:No conditions noted.The workgroup would like to see mappings between the source nursing terminologies andSNOMED CT, and for these mappings to be maintained, validated, and distributedthrough the UMLS. The workgroup recognizes the importance of the collaboration of thesource nursing terminology owners and the SNOMED CTG for Nursing in theappropriate inclusion and representation of nursing terms within SNOMED CT.

Appendix AANA-RecognizedTerminologiesAssessmentDiagnosisInterventionsOutcomesUpdates / CostMapped orConceptsIntegratedin SNOMEDCT?In theUMLS?NOTESScope IntentSNOMED CT X X X X Free thru UMLS inCategory 0 Convergent Terminology Group for Nursing—01/04as of 01/04 collaborates with ANA and terminology ownersABC Codes X No Category 3 Primarily administrative / billing codesNANDA X “License fee based on Integrated & Category 3 Fully integrated in SNOMED CTusage”mappingtablesavailableNIC X $5.00 per end user/yr Integrated & Category 3mappingtablesavailableNOC X $5.00 per end user/yr Plan to Category 3completeintegrationfor 1/2004OMAHASystemreleaseX X X Public Domain Integrated Category 1

ANA-RecognizedTerminologiesAssessmentDiagnosisInterventionsOutcomesUpdates / CostMapped orConceptsIntegratedin SNOMEDCT?In theUMLS?NOTESScope IntentHHCC X X X Annually / Copyrightedbut in Public Domain—free with permissionIntegrated(Diagnoses &Interventions;Outcomespending)Category 1Integrated into SNOMED CTPCDS X X X Only at VanderbiltUniversityDiscussionsContinuePNDS X X X Integrated &mappingtablesavailableICNP X X X X Demonstration /testing DiscussionsClinicalLOINCversionscontinueX X X Workgroupconvened byNLMCategory 3NONLY in use at Vanderbilt University; Plan tohave it coded according to clinical LOINC andmapped into SNOMEDN Version I not due for release TIL 2005YUnidentified overlap with SNOMED-CT; Notcomprehensive of nursing terms. Has conveneda nursing subcommittee—early stages.