NCM 110: NURSING INFORMATICS
STANDARDIZED NURSING TERMINOLOGY
CAMARINES SUR POLYTECHNIC COLLEGES
2ND SEMESTER A.Y. 2023 – 2024
INTRODUCTION
➢ The Nursing profession needs to conduct
research and generates measures and evidence
to prove that their nursing care improves quality,
safety, and healthcare outcomes.
➢ Nursing data are critical to the development of
data sets that can be used for analysis and
integrated with the data of healthcare disciplines
➢ Capture of Clinical care data is needed for better
patient care coordination and management
➢ Standardized Nursing Terminologies are needed
to:
1. Provide valid clinical care data
2. Allow data sharing across today’s HIT and
HER systems
3. Support evidence based decision making
4. Facilitate evaluation of nursing processes
5. Permit the measurement of outcomes.
HISTORICAL EVENTS
➢ IN 1859, Florence Nightigale named her six
cannons of care as “ what nurses do?” in her text
Notes on Nursing (1859)
➢ She considered the six cannons to be measure of
“Good Standards” essential for the practice of
nursing
➢ In 1939, Virginia Henderson published “Textbook
of the Principles and practices of Nursing in
which she delineated her “14 patterns of daily
living”
➢ Then her works are followed by several theories.
➢ Many models were all developed as approaches
to patient care; none referred to or predicted the
use of computers to support the implementation
of nursing practice standards
➢ In 1970, American Nurses Association (ANA)
approved nursing process as the standard of
professional nursing practice.
HEALTH TERMINOLOGIES
➢ International Classification of Disease (ICD)
▪ Was being used internationally for the
reporting of mortality and morbidity
statistics, was also being used by the U.
S federal government for payment of
healthcare services.
➢ Other hospital specialty departments initiated
different terminologies for payment of their
specific services
▪ Physician Current Procedural
Terminology (CPT): for surgical
procedures
▪ Logical Observation Identifier Names
and Codes: for laboratory test
➢ Nursing terminology development was motivated
by a number of factors:
1. The need to quantify nursing resources
2. The introduction of the electronic health
record in healthcare facilities
3. The development of knowledge bases and
growth of evidence based nursing practice.
NURSING AND COMPUTERS
➢ 1985
▪ The CCAN supported the conduct of
several conferences on computers in
nursing practice such as werley and her
development of the Nursing Minimum
Data Set (NMDS)
▪ Nursing Informatics combines nursing
science, information science, and
computer science to manage and
process nursing data, information and
knowledge to facilitate the delivery of
healthcare.
➢ 1992
▪ The CCAN’s name was changed to the
Database Steering Committee and
continued its involvement by approving
Nursing Informatics as new nursing
specialty.
▪ The Council developed the criteria for
Nursing Terminology as appropriate for
the documentation of Nursing practice.
▪ 2 Data Sets are recognized: Nursing
Minimum Data Set and Nursing
Management Minimum Data Set
▪ Metathesaurus
NURSING TERMINOLOGY CHALLENGES
➢ 2 Major Challenges:
▪ The existence of multiple, specialized
terminologies has resulted in areas of
overlapping content, areas for which
there was no content and large number
of different codes and terms
▪ Existing Terminologies most often were
developed to provide set pf terms and
definitions of concept human
interpretation, with computer
interpretation only a secondary goal
ADVANCE TERMINOLOGY SYSTEM IN NURSING
FORMAL TERMINOLOGIES
➢ Advance terminology system such as ICNP and
SNOMED-CT are a focus of today’s harmonizing
efforts.
➢ Both terminologies facilitated two important facets
of knowledge representation for HIT and HER
system that supports clinical care:
▪ Describing concept
▪ Manipulating and reasoning
➢ Advantages resulting from first facet includes:
 NCM 110: NURSING INFORMATICS
STANDARDIZED NURSING TERMINOLOGY

CAMARINES SUR POLYTECHNIC COLLEGES

2ND SEMESTER A.Y. 2023 – 2024

a. non ambigous representation of REFERENCE TERMINOLOGY MODELS FOR

concepts NURSING
b. facilitation of data abstraction or
deabsrtraction without loss of original
meaning
c. non ambigous mapping among
terminologies
d. data reuse in different context
e. data interoperability across settings
➢ Advantages resulting from second facet includes
a. auditing the terminology system
b. automated classification of new
concepts
c. an ability to support multiple inheritance
of defining characteristics

CHARACTERISTIC OF ADVANCE
TERMINOLOGIES
➢ Concept Oriented
➢ Domain Completeness
➢ Polyhierarchical organizations DEVELOPMENT OF ISO 18104:2003
➢ Atomic level ➢ Intendended to be “consistent with the goals and
➢ Non redundancy objectives of other specific health terminology
➢ Non ambiguity models in order to provide a more unified
➢ Concept permanence reference health model.
➢ Compositionality
➢ Synonym ONTOLOGIES
➢ Represent classes (also refereed to as concepts,
CONCEPT ORIENTATION categories, or types) and their properties (also
referred to as relations, slots, roles, or attributes).
➢ Also facilitate reasoning about the concept

OWL REPRESENTATION OF ICNP

➢ Intended for use where applications, rather than
humans, process information. As such, it should
be able to meet the requirements of advance
terminology systems the support contemporary
healthcare.

ICNP AS A TERMINOLOGY
➢ The primary motivation for an international
nursing terminology involves sharing and
comparing data across settings, countries, and
languages

MODEL STRUCTURES SNOMED-CT

➢ Schemata and Type Definitions
▪ Schemata incorporate domain-specific
knowledge about the typing constellation
of entities, attributes and events in the
real world and, as such, reflect plausible
combination of concept for naming a
nursing diagnosis or problem.
➢ Considered to be the most comprehensive,
multilingual clinical healthcare terminology in the
world and integrates, through external mappings,
concepts from many nursing terminologies.
NURSING MINIMUM DATA SET (NMDS)
➢ Identifies essential, common, and core data
elements to be collected for all patients/ clients
receiving nursing care includes three categories
of elements:
a. nursing care
 NCM 110: NURSING INFORMATICS
STANDARDIZED NURSING TERMINOLOGY

CAMARINES SUR POLYTECHNIC COLLEGES

2ND SEMESTER A.Y. 2023 – 2024

b. patient or client demographics

c. service elements

INTERNATIONAL NURSING MINIMUM DATA SET

(I-NMDS)
➢ Intended to build on and support data set work
already underway in individual countries.
➢ I-NMDS project focuses on coordinating ongoing
national-level efforts
➢ I-NMDS includes the core, internationally
relevant, essential, minimum data elements to be
collected in the course of providing nursing care
➢ These data can provide information to describe,
compare, and examin nursing practice around the
globe.

NURSING MINIMUM MANAGEMENT DATA SET

(NMMDS)
➢ The 18 NMMDS elements are organized into
three categories: environment, nursing care
resources, and financial resources
➢ Most appropriately focuses on the nursing
delivery unit/service/center of excellence level
across the settings
➢ Provides the structure for the collection of uniform
information that influences quality of patient care,
directly and indirectly.