Data Standards for Nursing

Data models, terminologies and structures used in healthcare IT and some in NurseMind:

  • Virginia Saba's Clinical Care Classification System, the only one created specifically for nursing and specifically for digital data processing
  • North American Nursing Diagnosis Association (NANDA) Nursing Interventions Classification (NIC)
  • International Classification for Nursing Practice (ICNP) ICNP - English
  • Nursing Outcomes Classification (NOC)
  • Georgetown Home Health Care Classification (HHCC)
  • Omaha System (covers problems, interventions, and outcomes)
  • ISO 18104:2003 -- a reference terminology model for nursing diagnoses and actions
  • ICD-10 -- 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD), a medical classification list by the World Health Organization (WHO). It contains codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases.
  • Systematized Nomenclature of Medicine (SNOMED)
  • Systematized Nomenclature of Medicine -- Clinical Terms (SNOMED CT)
  • Logical Observation Identifiers Names and Codes (LOINC) -- clinical lab tests and results
  • Continuity of Care Record (CCR) -- a document format to support communication from one caregiver to the next of a patient's meds, allergies, treatments, and care plan

For integration with hospital information systems (HISs), we support industry data interchange standards:

  • Health Level Seven (HL7) -- a comprehensive framework and related standards for the exchange, integration, sharing, and retrieval of electronic health information
  • DICOM (digital imaging)
  • IEEE 1073, Standard for Medical Device Communications (bedside devices in the ICU, OR, and ER)
    being released as ISO standards
  • ASC X12 message standards for claims, eligibility, purchase orders, invoices, payments and other business documents organized as transaction sets
  • Uniform Code Council (UCC) and Health Industry Business Communications Council (HIBCC) bar codes -- patient wristbands, medication labels, etc.
  • CDISC -- format for reporting data collected in clinical trials
  • NCPDP -- structure for transmitting prescription requests and fulfillment
  • ICD-9 diagnosis and disease codes widely used in billing, claims, and reimbursements
  • UMLS -- database of medical terminologies and related tools for concept mapping
  • CDA -- data exchange model for discharge summaries, progress notes, and certain other clinical documents