STANDARDIZED NURSING LANGUAGE/TERMINOLOGIES

The original impetus to develop a standard vocabulary for describing health-care phenomena in
nursing was to facilitate more widespread use of computers in documentation of care. A standard
vocabulary permits the coding of nursing information so that data are available, reliable, valid,
and comparable across settings. More importantly, use of a standard vocabulary as opposed to
free text notes, ensures that information regarding categories of nursing diagnoses, interventions,
and outcomes are easily retrievable and trackable across settings. Therefore, in order to have the
capacity to track a nurse’s contribution to these outcomes, a standard vocabulary for nursing is
essential. These context-free elements of the process, organized into taxonomic structures for
diagnosing, treating, and organizing nursing care are based upon research evidence that can be
used to direct nurses’ clinical decision-making.
Using standardized terminology within electronic health records is critical for nurses to
communicate their impact on patient care to the multidisciplinary team. The universal
requirement for quality patient care, internal control, efficiency and cost containment, has made
it imperative to express nursing knowledge in a meaningful way that can be shared across
disciplines and care settings. The documentation of nursing care, using an electronic health
record, demonstrates the impact of nursing care on patient care and validates the significance of
nursing practice
Nursing has its “own language, including unique terminology and classifications that facilitate
the efficient delivery of high-quality health care. It’s important that advanced practice nurses
have an acute understanding of the standardised nursing terminology lists and classification
systems, as this knowledge can potentially establish the line that separates an efficient health
care organisation from an inefficient one. Each of the Nursing language /terminology is
developed for a variety of care settings. Selecting the appropriate nursing terminology
implementation for use in the EHR can be daunting. Professional informatics standards such as
nursing informatics standards address the concepts of using standardized nomenclatures coding
systems and vocabularies in practice. These are particularly important as the electronic health
record and associated electronic nursing documentation advance.
It is important to understand the many ways in which utilization of nursing languages will
provide benefits to nursing practice and patient outcomes. Again, the development of
classification systems for nursing care, nursing information management systems and nursing
data sets provide tools that nurses in all countries could use to describe nursing and its
contributions to health. An often-referenced quote by Norma Lang says it all “If we cannot name
it, we cannot control it, finance it, teach it, research it, or put it into public policy”.

Definition of Standardized Nursing Language (SNL):

 i. Standardized nursing language (SNL) is a commonly-understood set of terms used to
describe the clinical judgments involved in assessments (nursing diagnoses), along
with the interventions, and outcomes related to the documentation of nursing care.
ii. Standardized nursing language (SNL) consists of health-related concepts and
provides a common language that enables a consistency of clinical data across
specialties and patient care sites.
ANA has put in place a committee to guide the standards terminologies used in nursing practice
known as Committee for the Nursing Practice Information Infrastructure (CNPII). There are
currently twelve terminology sets that support nursing practice approved by the American Nurses
Association (ANA, 2012). They are:
i. Clinical Care Classification (CCC) or Home Health Care Classification (HHCC)
ii. International Classification of Nursing Practice (ICNP)
iii. NANDA International (NANDA-I)
iv. Nursing Intervention Classification (NIC)
v. Nursing Outcome Classification (NOC)
vi. Omaha System
vii. Perioperative Nursing Data Set (PNDS)
viii. Nursing Minimum Data Sets (NMDS)
ix. Systematic Nomenclature of Medicine - Clinical Terms (SNOMED-CT)
x. Logical Observation Identifiers Names and Codes (LOINC)
xi. Alternative Billing Codes (ABC)
xii. Patient Care Data Set (PCDS)

Clinical Care Classification

The Clinical Care Classification (CCC), originally named the Home Health Care Classification
(HHCC), was designed for electronic coding to predict home healthcare use for Medicare
patients. The Clinical Care Classification or HHCC was developed in 1991. It has since evolved
to be a full clinical care terminology and has been integrated into some electronic healthcare
systems. There are 176 nursing diagnoses and 201 Core Interventions’ in the CCC. Outcome is
based on the original nursing diagnosis and is documented as improved, stabilized, or
deteriorated.

Its primary purpose is to provide a structured and consistent method to assess and classify
patients in order to determine the resources required to provide home health and ambulatory care
services including the outcome of care. The coding system has been designed to link and map the
six steps of the nursing process and facilitates the design of critical care protocols and/or
pathways to make this a very useful nomenclature.

International Classification of Nursing Practice (ICNP)

Another seminal or strong initiative was undertaken by the International Council of Nurses
(ICN) in 1989, in response to a proposal by the Canadian and American Nurses’ Associations.
The associations had expressed concern that it was not possible to name nursing’s patient
problems and to describe nursing’s distinctive contributions to solving or alleviating them. The
ICNP terminology was therefore developed to establish an international standard for the
description and comparison of nursing practice and to facilitate the development of cross-
mapping between local terms and other terminologies.
NANDA - I
NANDA International nursing diagnoses is an electronic healthcare record that provides a
framework for nurses to document and state priority needs and problems to address within the
health encounter; whether in the inpatient, ambulatory or homecare/hospice setting. The
diagnoses are used to identify human responses to risks, disease, injury or health promotion. The
nurse uses a critical thinking process to diagnose these human responses. This involves
interpretation of human behaviors related to patient, family or a community’s health. In NI,
electronic health records provides the ability to select nursing interventions to achieve outcomes
for which a nurse is accountable.

The NANDA- international nursing diagnoses are used to develop problem lists, assessments,
plans of care and clinical pathways as a means to label patient conditions. Additionally, an
electronic health record developer adds the definition, defining characteristics, risk and related
factors as knowledge reference text for students and novice nurses to access while using the
electronic health record to guide the selection of an accurate diagnosis. The structure of the
taxonomy has 3 levels:
i. Domain: is an area of interest (functional, physiological, psychosocial,
environmental)
ii. Class: is a division of diagnostic concepts by type of response (activity/exercise,
behavior or knowledge, healthcare system
iii. Nursing diagnosis: defined as “a clinical judgment about an individual, family or
community responses to actual or potential health problems/life processes”

Nursing Interventions Classification (NIC)

The Center for Nursing Classification was established by the University of Iowa in 1995 to
facilitate the ongoing research of two classification systems developed by that University: (i) the
Nursing Interventions Classification (NIC), and (ii) the Nursing Outcomes Classification (NOC).
Nursing intervention is defined as any treatment, based upon clinical judgment and knowledge
that a nurse performs to enhance patient/client outcomes. It is a comprehensive, research-based,
standardized classification of nursing interventions, there are interventions performed
specifically by nurses. The use of NIC facilitates the analysis of the impact of activities on
patient outcomes. It specifies interventions which are both independent and inter-dependent
and the nursing activities required to implement them and include both direct and indirect care
aimed at individuals, families and the community.

NIC Taxonomy has 7 domains and 30 classes and 554 interventions. Each intervention has a
unique identifier to facilitate computerization, a label, a definition, and a detailed set of
activities that describes what a nurse does to implement the intervention which can also be
used for reimbursement of nursing interventions.
 The use of the NIC classification system in an electronic health record facilitates the
appropriate selection of nursing interventions to demonstrate the impact of nursing
and help communicate the nurse work to other clinicians on the interdisciplinary
healthcare team.
 Standardized nursing intervention enables researchers to examine the effectiveness and
cost that can be used to allocate nursing care.
 In nursing education curricula, standardized nursing intervention facilitates the teaching
of clinical decision making to nurse learners at the point-of-care by articulating the
nursing process as it is used in clinical practice
 NIC use also enhance implementation of plans of care, critical pathways, order sets,
patient education and data sets for the evaluation of care at the individual or unit level.

Nursing Outcomes Classification

NOC was first developed in 1991. It is a comprehensive and standardized classification of
patient/client outcomes. Its purpose is to evaluate the effects of nursing interventions and can be
used in all health care settings and by all nursing specialties. The nursing outcomes classification
(NOC) is intended to provide a measurable way to evaluate the effect of nursing interventions on
patient progress. It consists of 490 outcomes with a list of indicators to evaluate the patient
status. Each outcome has a unique identifier to facilitate computerization, a definition and a list
of indicators that can be used to evaluate patient status in relation to the outcome
OMAHA System
The OMAHA classification system was developed in the early 1970s specifically for the Visiting
Nurses Association of Omaha for classifying clients’ problems in community and home
healthcare settings. Omaha System was originally devised as a way for home healthcare nurses
to document their care. The system consists of three aspects: (i) problem classification scheme;
(ii) intervention scheme; and (iii) problem rating scale for outcomes. Like the other nursing-
specific terminologies, with the exception of the NANDA-I, NIC & NOC (NNN) terminologies,
the Omaha System includes within it, terminology for nursing diagnosis, interventions, and
outcomes. It is widely used in home care, public health, outpatient, case management, school,
hospital and other practice setting
Perioperative Nursing Data Set
The Perioperative Nursing Data Set (PNDS) has been developed by the Association of Peri-
operative Registered Nurses (AORN), Denver, USA. It consists of 93 nursing diagnosis, 151
nursing interventions, and 38 nurse sensitive patient outcomes which together describe the peri-
operative patient experience from pre-admission to discharge. The Perioperative Nursing Data
Set (PNDS) is intended to make visible to administrators the patient problems that
perioperative nurses manage. It provides a consistent method for classifying and documenting
perioperative patient care across the surgical continuum, allowing for the monitoring and
benchmarking of patient outcomes and operating room efficiency. The PNDS provides a
framework to standardize clinical documentation within an HER and is the only perioperative
nursing language recognized by American Nurses Association (ANA).
Nursing Minimum Data Sets (NMDS)
The Nursing Minimum Data Set (NMDS) is a minimum set of items of information with uniform
definitions and categories concerning the specific dimension of nursing. It is the minimum
number of data element types that are needed to enable knowledge discovery to suit a specific
purpose. In healthcare, Minimum Data Set (MDS) is a standardized, comprehensive assessment
of a client functional, medical, psychosocial, and cognitive status. It is commonly used in long-
term care facilities and outpatient and home-based social service programs for older
adults. The MDS contains items that measure physical, psychological and psycho-social
functioning. The items give a multidimensional view of the patient's functional capacities, and
can be used to present a nursing home's profile.
The nursing care elements of the NMDS include nursing diagnosis, nursing intervention, nursing
outcome, and intensity of nursing care. Its primary contribution to practice is that it provides data
for quality improvement and trend tracking while in nursing education, it facilitates awareness in
students of the necessity to document care appropriately using the nursing process model.
The NMDS includes three broad categories of elements:
i. Nursing care elements
ii. Patient or client demographics elements
iii. Service elements
Patient Care Data Set (PCDS)
The Patient Care Data Set (PCDS) was developed by Judy Ozbolt at the University of Virginia
along with member institutions of the University Health System Consortium. It is a database of
words and phrases commonly used by acute care providers and can be organized in multiple
ways to yield highly customizable documentation. The use also extends to include other acute
care providers such as nurses nutritionists and physical therapists. PCDS serves as a set of
standard terms or documenting tool to aid acute care givers effectively represent and capture
clinical data in patient care information systems. PCDS is a compilation of terms that represent
patient problems, patient care goals, goal achievement status, and patient care orders.
The PCDS was not developed as a classification system, but as a data dictionary of elements to
be included in and abstracted from clinical information systems. The terms are organized into 22
components, which were modified from those identified by Virginia Saba in the Home Health
Care Classification. There are: Activity, Circulation, Cognition, Coping and Mental Health,
Fluids and Electrolytes, Gastrointestinal Function, Health Knowledge and Behaviors,
Immunology, Medications and Blood Products, Metabolism, Nutrition; Physical Regulation;
Pre-, Intra, and Post-Procedure; Respiration; Role Relationships, Safety, Self-Care, Self-
Concept, Sensation, Pain and Comfort, Tissue Integrity, Tissue Perfusion, Urinary Elimination
Interdisciplinary Terminologies
The ANA recognized three interdisciplinary terminologies, the Alternative Billing Concept
(ABC) Codes, SNOMED CT, and LOINC. The ABC codes are not used in direct clinical care
and are not addressed here.
Systematized Nomenclature of Medicine - Clinical Terms (SNOMED-CT)
SNOMED- CT is a comprehensive, scientifically validated clinical terminology and
infrastructure for healthcare containing a broad coverage of terminology supporting healthcare
documentation through the continuum of care. SNOMED CT provides a consistent way of
indexing, storing, retrieving and aggregating clinical data across specialties and sites of care. The
use of SNOMED CT within electronic health records provides interoperable (ability to share data
between different computer systems) data extraction and analysis that can be shared across
clinicians, clinical settings and organizations both nationally and internationally.

Logical Observation Identifiers, Names, and Codes (LOINC)

Although originally designed for communicating laboratory assessments, the purpose of the
Logical Observation Identifiers, Names, and Codes (LOINC) has expanded to include the coding
of assessment data for the EHR. These measures include vital signs and assessments from
standardized nursing terminologies.
Alternative Billing Concept (ABC) Codes
ABC Coding is a standardized multidisciplinary coding system that is recognized by the
American Nurses Association as supporting nursing practice. ABC codes were originally
developed to process claims addressing conventional, complimentary, and alternative health care
services not routinely included in traditional medical billing codes. These codes provide a more
detailed description of health care services to ensure appropriate reimbursement and fill in the
missing gaps found in the older medical coding systems making the new billing system more
reliable and cost effective.
It is important for nursing as a profession to be included in the interoperable electronic medical
record that is going to be the future of health care. The ABC coding system contains
approximately 800 nursing procedures gathered from the Nursing Interventions Classifications
(NIC). With the ABC coding system, these interventions can be documented and interfaced with
an electronic health record justifying nursing care and the profession.
Benefits of Implementing Standardized Terminologies within Electronic Health Records
 The use of standardized nursing languages helps nurses understand patients' needs with
precision and speed
 Patients benefit from continuity of care being facilitated through the use of standardized
terminologies which improve and makes communication unambiguous between
clinicians.
 Organizations benefit by being able to measure nursing care and its impact on patient
care through patient record instead of costly manual chart audits.
 Furthermore, standard terminologies provide administrators with the actual costs and
benefits of nursing care which enhance informed decisions regarding staffing ratios.
 The profession benefits because standardized terminologies expose and validate the
contribution of nursing to healthcare and patient safety.
 The profession also benefits as SNLs provide a means to document, store, and retrieve
evidence-based practice in a semantic way to facilitate nursing research
 The use of standardized nursing language incorporate nursing descriptions of delivered
care into healthcare records in a way that maintains uniqueness of care provided by
nurses different from other healthcare providers
 SNLs facilitate better communication among Nurses and other healthcare providers.
 SNLs increased visibility of nursing interventions: Nurses need to express exactly what it
is that they do for patients. Nursing has a long tradition of over-reliance on handing down
both information and knowledge by word-of-mouth which has made their
work/contribution invisible..
 The use of a standardized language to record nursing care can provide the consistency
necessary to compare the quality of outcomes for various nursing interventions across
settings.
 When the nursing care data stored in these computer systems are in a standardized
nursing language, Local, State and National data repositories can be constructed that will
facilitate benchmarking with other hospitals and settings that provide nursing care.
 Nurse educators use standardized terminologies in the curriculum to teach nursing
concepts that are critical in the nursing process and are vital to developing new nurses
 Standardized nursing terminologies facilitates critical thinking and decision making at the
point of care
 It also help nurses to understand patients’ needs with precision and speed, making
accurate nursing diagnoses which facilitates the selection of more effective nursing
interventions that lead to better outcomes
 Each country benefits by having retrievable coded data that can be aggregated into
informative reports or data sets. These reports allow countries to compare nursing’s
 contribution to care both nationally and internationally using the International Nursing
Minimum Data Set.
 The use of standardized languages can provide a launching point for conducting research
on standardized languages.