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GB/T 25515-2010: Health informatics -- Integration of a reference terminology model for nursing
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GB/T 25515-2010: Health informatics -- Integration of a reference terminology model for nursing

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Health informatics.Integration of a reference terminology model for nursing ICS 35.240.80 L09 National Standards of People's Republic of China Health Information Science Nursing reference term model integration (ISO 18104..2003, IDT) 2010-12-01 release 2011-05-01 implementation General Administration of Quality Supervision, Inspection and Quarantine of the People's Republic of China China National Standardization Management Committee released Directory Preface I Introduction II 1 Scope 1 2 normative reference document 1 3 Terms and definitions 2 4 Nursing Diagnostic Reference Terminology Model 2 5 Nursing Activity Reference Terminology Model 4 Appendix A (informative) Example of Nursing Diagnostic Section 7 Appendix B (informative) Example of Nursing Activity Section 12 Appendix C (informative) Examples of sections of diagnostics and activities for non-nursing subjects 17 Appendix D (informative) Model conventions in model 21 Appendix E (informative) model build basis 22 Appendix F (informative) Reference Terminology Model Related Issues Summary 24 Reference 25

Foreword

This standard is equivalent to ISO 18104..2003 "Health Information Science Reference Terminology Model Integration". The ISO 18104..2003 is subject to the following editorial changes. - "Additional nobackgroundtermsanddefinitionsfrom" in the first paragraph of Chapter 3 of ISO 18104..2003 ISO 1087-1..2000 [27] areprovidedinAnnexA. "Should be deleted when it is published from draft to official standard Of the part, but its official publication of the text has not been deleted, so this standard deleted the sentence; - ibid., The references [27] of the original text in the sentence are not referenced elsewhere, and are therefore referred to in this standard accordingly delete. Appendix A, Appendix B, Appendix C, Appendix D, Appendix E and Appendix F of this standard are informative. This standard is proposed and centralized by China Standardization Research Institute. The drafting of this standard unit. China Institute of Standardization. This part of the main drafters. Chen Huang, Shi Lijuan, Dong continuous, Yang Xuefeng, Zhang Xiumei, Zhou Jimei, Li Xian, Guo Xiaoning, Huang Feng, Jiao Jianjun.

Introduction

The development of nursing terminology is driven by a number of factors. - the implementation of computer-aided systems in clinical facilities; - the request for reimbursement for the provision of care services; --- document that is conducive to improving the care of the patient's medical care; --- student education; The enhancement of nursing knowledge system. Nursing terms, whether based on paper or computer form, are designed as enumerable categories and are implemented in medical care Point interface terminology and management terminology to check cross-facility care data. There are currently many standardized terms, but there is no set of standards The terminology is perfectly applicable to the field of care in terms of width or particle size. Moreover, there is no integrated care area, suitable for computer The concept of conceptualization. In recent years, however, great progress has been made in developing reference-oriented terminology that supports the field of care. There are also Some of the major challenges lie in developing a reference term model that supports the concept of care, as well as other models of the model and health care Type of integration [1]. A great deal of effort has been made to address these challenges. Among the more prominent are the European Committee for Standardization (CEN / TC251) will ICNP® (International Nursing Practice Classification) project, telemedicine logo (TelenurseID) and other related work in Europe Synthesize a pre-standard ENV14032 [2-6]. In addition, the standard also relates to the International Medical Information Institute (IMIA) Nursing Informatics Group, Nursing Terminology Summit, SNOMED® Nursing Terms Group, HL7 and LOINC (Clinical Logic Observe the Identifier, Name and Code) [3] [7] [8] [9]. In contrast, the CEN pre-standard describes a broad generic structure for nursing diagnosis and care activities, and this standard is particularly Focusing on the reference term model rather than the conceptual structure represented by other information models. In addition, in order to achieve with other health care models Consolidated targets, the reference term model for nursing diagnosis and care activities in this standard attempts to develop terminology and development beyond the field of care Information model standards are coordinated. Health Information Science Nursing reference term model integration

1 Scope

1.1 main purpose The purpose of this standard is to establish a nursing reference term model that is consistent with the tasks and objectives of other specific health term models so that Provide a more unified reference health model. This standard gives a reference term model for nursing diagnosis and care activities, Implementation of the relevant terms and definitions. The potential use of this reference term model is. a) support the definition of the concept of nursing diagnosis and nursing activities that reflect a wide range of roles and practical facilities; b) promote the characterization of nursing concepts and their relationships for nursing diagnosis and care activities suitable for computer processing; c) providing a framework for generating a composite representation from the atomic concept of the reference term; d) promote the construction of conventional forms of nursing terminology, which makes mapping between terms easier; e) promote the concept of nursing diagnosis and care activities between different terminology (including terminology developed for interface and statistical classification) Mapping; f) be able to systematically evaluate terminology and related term models to achieve their coordination; g) provide a language that describes the conceptual architecture of nursing care and nursing activities so that it is appropriate for other reference term models and information models integrated. 1.2 Scope of application The target group of this standard is. a) Encode systems and terminology developers, (the system and terminology) include the concepts of nursing diagnosis and care activities to assist specific Language development, improvement and maintenance, and comparison between different systems; b) other health care providers refer to the developer of the term model to clarify the relationship and overlap between nursing concepts; c) Information model personnel, knowledge engineers, and engineers who have modeled health information management systems (eg eHealth records and decision support systems) Standard developers to describe the expected content for the term field for special attributes and data elements in the information system; d) Information system developers who need a clear conceptual system for internal organization, data warehouse management and middleware services; e) natural language processing software developers to facilitate the coordination of their output and coding systems; f) Developers who use standard (language) standards for health care documentation. 1.3 Not applicable The following topics do not apply to this standard. a) comprehensive classification of nursing diagnosis and nursing interventions; b) detailed classification, naming or reference terms for nursing diagnosis or nursing activities; c) descriptors and guides representing the context in the records of electronic health records; d) a detailed list of all potential details that may appear in the statement of care diagnosis and care activity; e) detailed list of descriptors for nursing diagnosis and nursing activities; f) the relationship between health professionals; g) Conceptual communication between eHR records of nursing diagnosis and nursing activities.

2 normative reference documents

The terms of the following documents are hereby incorporated by reference into this standard. Whichever is the date of the reference file, which is followed by all ...