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ANA Recognized Terminologies and Data Element Sets

Setting Where Developed Content Definition


Data Element Sets
1. NMDS All Nursing Clinical Data Elements Minimum set of items of
Nursing Minimum Data Set information with uniform
Currently Recognized definitions and categories
concerning the specific
dimension of professional
nursing, which meets the
information needs of multiple
data users in the health care
system.
2. NMMDS All Settings Nursing Administrative Data Elements Data variables categorized into
Nursing Management Minimum environment, nurse resources,
Data Set and financial resources that are
Currently Recognized needed to inform the decision
making process of nurse
executives related to leading and
managing nursing services
delivery and care coordination.
Interface Terminologies
3. CCC Home Care Diagnoses, Interventions, and Terminology that identifies the
Clinical Care Classification Outcomes discrete data elements of
Currently Recognized nursing practice. Standardized
framework and coding structure
of diagnoses interventions, and
outcomes for assessing,
documenting, and classifying
care in all healthcare settings.
Used to track and measure
patient/client care holistically
over time, across settings,
population groups, and
geographic locations.
4. ICNP® All Nursing Diagnoses, Interventions, and Combinatorial terminology for
International Classification of Outcomes nursing practice that facilitates
Nursing Practice cross-mapping of local terms and
Currently Recognized existing vocabularies and
classifications. Includes Nursing
phenomena (nursing diagnoses),
Nursing actions, Nursing
outcomes.
5. NANDA All Nursing Diagnoses A nursing diagnoses classification
NANDA International developed to describe the
Currently Recognized important judgments nurses
make in providing nursing care
for individuals, families, groups,
and communities. These
judgments, or diagnoses, are the
basis for selection of nursing
outcomes and interventions. The
terminology is updated every
two years.
6.NIC All Nursing Interventions A comprehensive, research-
Nursing Intervention Classification based, standardized
Currently Recognized classification of interventions
that nurses perform and use for
clinical documentation,
communication of care across
settings, integration of data
across systems and settings,
effectiveness research,
productivity measurement,
competency evaluation,
reimbursement, and curricular
design. An intervention is
defined as "any treatment, based
upon clinical judgment and
knowledge, that a nurse
performs to enhance
patient/client outcomes." NIC
includes interventions that
nurses do on behalf of patients,
both independent and
collaborative interventions, both
direct and indirect care.
7. NOC All Nursing Outcomes A comprehensive, standardized
Nursing Outcome Classification classification of patient/client
Currently Recognized outcomes developed to evaluate
the effects of nursing
interventions. An outcome is a
measurable individual, family, or
community state, behavior or
perception that is measured
along a continuum and is
responsive to nursing
interventions.

8. OMAHA SYSTEM Home Care, Public Diagnoses, Interventions, and Comprehensive practice and
Omaha System Health, and Outcomes documentation tool that can be
Currently Recognized Community used by multidisciplinary health
care practitioners in any setting
from the time of client admission
to discharge. Omaha System
includes an assessment
component (Problem
Classification Scheme), an
intervention component
(Intervention Scheme), and an
outcomes component (Problem
Rating Scale for Outcomes)
9. PCDS Acute Care Diagnoses, Interventions, and *Includes terms and codes for
Patient Care Data Set Outcomes patient problems, therapeutic
Retired goals, and patient care orders.
10. PNDS Perioperative Diagnoses, Interventions and Describes perioperative nursing
Perioperative Nursing Data Set Outcomes practice with a sub-set of terms
Currently Recognized that specifically describe
perioperative nursing diagnoses,
nursing interventions, and
patient outcomes in surgical
settings from pre-admission until
discharge.

Multidisciplinary Terminologies
11. ABCCodes Nursing and Other Interventions Terminology that describes
ABC Codes alternative medicine, nursing
Currently Recognized and other integrative healthcare
interventions. Includes type of
provider and recognized level of
licensed practitioner by state.
12. LOINC® Nursing and Other Outcome and Assessments Set of universal names and ID
Logical Observation Identifiers codes for identifying laboratory
Names and Codes and clinical test results which can
Currently Recognized be used to describe laboratory
and clinical results when store in
computer databases or
transmitted in electronic
messages. The clinical portion of
the LOINC database includes
entries for vital signs,
hemodynamics, intake/output,
EKG, obstetric ultrasound,
cardiac echo, urologic imaging,
gastroendoscopic procedures,
pulmonary ventilator
management, selected survey
instruments, and other clinical
observations.
13. SNOMED CT Nursing and Other Diagnoses, Interventions, and Core terminology that provides a
Systematic Nomenclature of Outcomes common language that enables a
Medicine Clinical Terms consistent way of capturing,
Currently Recognized sharing and aggregating health
data across specialties and sites
of care.

Updated May 11, 2006 http://www.nursingworld.org/npii/terminologies.htm

*Saba, Virgina and McCormick, Kathleen (2006). Essentials of Nursing Informatics. Philippines: McGraw-Hill Companies, Inc.

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