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Concept Oriented Terminology: Service Elements

The document outlines the key elements and standards related to nursing care documentation and terminology. It includes elements like unique patient identifiers, dates, diagnoses, interventions, and outcomes. It also lists various nursing terminologies, classifications, taxonomies, and standards used to define concepts, relationships, and ensure data exchange between systems. The goal is to have standardized terminology and conceptual models for capturing the essential elements of nursing care.

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Shaira Ann Calamba
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43 views

Concept Oriented Terminology: Service Elements

The document outlines the key elements and standards related to nursing care documentation and terminology. It includes elements like unique patient identifiers, dates, diagnoses, interventions, and outcomes. It also lists various nursing terminologies, classifications, taxonomies, and standards used to define concepts, relationships, and ensure data exchange between systems. The goal is to have standardized terminology and conceptual models for capturing the essential elements of nursing care.

Uploaded by

Shaira Ann Calamba
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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UNIQUE FACILITY

UNIQUE PATIENT PERSONAL


HEALTH RECORD IDENTIFICATION

UNIQUE # OF
DATE OF BIRTH
PRINCIPLE RN NURSING DIAGNOSIS

EPISODE ENCOUNTER SEX


NURSING
DATE INTERVENTION
RACE/ETHNICITY
TERMINATION DATE NURSING OUTCOME
RESIDENCE
DISPOSITION OF INTENSITY OF
PATIENT NURSING CARE

PATIENT
SERVICE ELEMENTS DEMOGRAPHIC
NURSING CARE ELEMENT
ELEMENTS
NURSING MINIMUM
DATA SET

ELEMENTS

TERMINOLOGIES CONCEPT ORIENTED HEALTHCARE DATA NURSING NOMENCLATURES


DEFINING TERMINOLOGY STANDARDS TERMINOLOGIES
RELATIONSHIPS
CLASSIFICATIONS

CATEGORIES OF
CONCEPT STANDARDS TWO IMPORTANT TAXONOMY
CONCEPT

TERM
DATA EXCHANGE/ STANDARDIZED
MESSAGING SYNTAX SEMANTICS
OBJECTS TERMINOLOGIES
STANDARDS

DOCUMENT
STANDARDS
NANDA

CONCEPTUAL
STANDARDS NIC

APPLICATION NOC
STANDARDS

OMAHA SYSTEM
TERMINOLOGY
STANDARDS
SABA’s HOME
HEALTHCARE
ARCHITECTURE
STANDARDS
UMLS
METATHESAURUS

CCC

PNDS

SNOMED CT

PCDS (version 4.0)

INTERNATIONAL
CLASSIFICATION FOR
NURSING PRACTICE

NURSING
MANAGEMENT
MINIMUM DATA SET

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