Nursing Resources for Standards and Interoperability
Target Audience: nurses, nursing students, nursing informaticists, and those exploring nursing terminologies for systems development or integration purposes. These nursing terminology resources can help you discover:
- The role of SNOMED CT and LOINC in implementing Meaningful Use (MU) in the United States (US).
- International collaboration to harmonize nursing terminologies and facilitate interoperability.
- How to find Concept Unique Identifiers (CUIs) and extract synonymy from the Unified Medical Language System (UMLS) Metathesaurus between SNOMED CT and other nursing terminologies such as CCC, ICNP, NANDA-I, NIC, NOC, The Omaha System, and PNDS (see 'Other Nursing Terminologies' section below).
- Additional resources for nursing clinical documentation purposes.
SNOMED Clinical Terms (SNOMED CT) is a standardized terminology used for clinical documentation in electronic health information systems. The International Health Terminology Standards Development Organisation (IHTSDO) owns, maintains, and distributes SNOMED CT. The National Library of Medicine, the United States National Release Center for the IHTSDO, provides access to SNOMED at no cost for use within the US. SNOMED CT is the most comprehensive, multilingual clinical healthcare terminology in the world. The terminology covers a wide range of clinical specialties, disciplines and requirements. This range of coverage allows for wider sharing and reuse of structured clinical information. With over 2 million components in SNOMED CT, domains such as nursing are generally well-covered with concepts specific for nursing diagnoses, interventions, and patient outcomes.
In the United States, SNOMED CT is one of the standards named for Federally Mandated use for the electronic exchange of clinical health information. Additionally, SNOMED CT is being implemented internationally as a standard within other IHTSDO Member countries. Specifically in the US, the US Edition of SNOMED CT must be used for reporting and problem lists in the patient summary record. One way that NLM has provided assistance with this criterion is with the Clinical Observations Recording and Encoding (CORE) Problem List Subset of SNOMED CT. Additionally the Nursing Problem List Subset of SNOMED CT may be beneficial. It's primary purpose is to facilitate the use of SNOMED CT for coding terminology related to diagnoses. The Nursing Problem List Subset is updated regularly.
Additionally, the IHTSDO and the International Council for Nurses (ICN), producers of the International Classification of Nursing Practice (ICNP), are collaborating in an effort to harmonize nursing terminology and emphasize interoperability between health information systems. Currently, IHTSDO and ICN are developing an equivalence table of nursing diagnoses and interventions between SNOMED CT and ICNP. The Baseline Release equivalence table is available on the SNOMED CT downloads page and in the latest International Release of SNOMED CT.
The IHTSDO Nursing Special Interest Group is a community of practice for the nursing profession, supporting worldwide nursing participation in the development, validation, uptake, implementation, and correct use of SNOMED CT and related products. They welcome participation from anyone interested in ensuring that SNOMED CT supports nursing requirements for electronic documentation and communication of patient care in any setting.
Logical Observation Identifiers Names and Codes (LOINC) is a clinical terminology for clinical and laboratory observations. The Regenstrief Institute owns, maintains, and distributes LOINC. The NLM provides access to LOINC via the UMLS. LOINC provides the formal names and standardized codes for laboratory and other clinical observations. The data covers laboratory terminology, vital signs, hemodynamics intake/output, EKG, obstetric ultrasound, cardiac echo, urologic imaging, gastroendoscopic procedures, pulmonary ventilator management, and selected survey instruments such as the Braden Scale.
LOINC, along with SNOMED CT, is part of a suite of designated standards for use in US Federal Government systems for electronic exchange of clinical health information. For nursing the LOINC terminology should be used to encode assessments and clinical outcomes.
In 2002, LOINC was recognized by the American Nurses Association (ANA) as a terminology for use by nursing. At that time, the Clinical LOINC Nursing Subcommittee was developed. The mission of the subcommittee is to provide LOINC codes for observations at key stages of the nursing process, including assessments, goals, and outcomes, and to meet the needs for administrative and regulatory data related to nursing care. The Subcommittee’s scope of responsibility includes: 1) triage content related to nursing and assist with understanding; 2) fill in the identified “gaps” in LOINC; 3) work with those who are requesting nursing content so the request will be in a “fit” condition to use; and 4) educate nursing regarding LOINC development and use.
These are additional terminologies used by nurses for nursing care documentation that are found in the UMLS.
Clinical Care Classifications (CCC)
CCC is a standardized terminology that provides a coding structure to assess, document, and classify patient care. Virginia Saba and colleagues at Georgetown University School of Nursing developed CCC. Please see the link for additional information about CCC in the UMLS and the current version of CCC in the Metathesaurus.
International Classification for Nursing Practice (ICNP)
ICNP in an international standardized terminology that provides description and comparison of nursing practice (e.g. nursing diagnosis, actions, and outcomes) and allows for cross- mappings between other terminologies. The International Council of Nurses (ICN) produces and maintains the ICNP. Please see the link for additional information about ICNP in the UMLS and the current version of ICNP in the Metathesaurus.
NANDA International (NANDA-I)
NANDA-I is a standardized classification system for nursing diagnoses. NANDA International currently develops and maintains NANDA-I. Please see link for additional information about NANDA-I in the UMLS and the current version of NANDA-I in the Metathesaurus.
Nursing Interventions Classifications (NIC)
NIC is a standardized terminology to classify nursing interventions. The University of Iowa College of Nursing develops and maintains NIC. Please see the link for additional Information about NIC in the UMLS and the current version of NOC in the Metathesaurus.
Nursing Outcomes Classification (NOC)
NOC is a standardized classification system of nursing patient outcomes for evaluation of nursing interventions. The University of Iowa College of Nursing develops and maintains NOC. Please see the link for additional information about NOC in the UMLS and the current version of NOC in the Metathesaurus.
The Omaha System (OMS)
Omaha is a standardized taxonomy used to document needs, describe interventions, and measure outcomes. The Omaha System Board of Directors maintains Omaha. Please see the link for additional information about Omaha in the UMLS and the current version of Omaha in the Metathesaurus.
Peri-operative Nursing Data Set (PNDS)
PNDS is a standardized nursing vocabulary that includes nursing diagnoses, interventions, and patient outcomes. The Association of periOperative Registered Nurses (AORN) develop and maintain PNDS. Please see the link for additional information about PNDS and the current version in the Metathesaurus.
Additionally, nurses need to be aware of other terminologies that are used in health information technology solutions. The most common terminologies in this category are: RxNorm, Current Procedural Terminology (CPT), International Classification of Diseases (ICD and the clinical modification used in the USA), and terminologies used in specific situations (HL7 has numerous standardized terminologies for use in its models), and others. Finally, NLM hosts the Value Set Authority Center (VSAC). VSAC contains values sets that populate electronic quality measures and other Meaningful Use artifacts.
Leveraging UMLS Synonymy to Extract Nursing Terms from SNOMED CT
NLM has created training resources and documentation to assist in finding synonymy between nursing terminologies and SNOMED CT. The SNOMED CT and Nursing Terminology Training Resources page provides resource documentation on how users can extract synonymy via the UMLS Metathesaurus Browser or MetamorphoSys.