ENV 14032:2001

SLOVENSKI STANDARD
01-oktober-2003
Zdravstvena informatika – Sistem konceptov za podporo zdravstveni negi
Health Informatics - System of concepts to support nursing
Ta slovenski standard je istoveten z: ENV 14032:2001
ICS:
35.240.80 Uporabniške rešitve IT v IT applications in health care
zdravstveni tehniki technology
2003-01.Slovenski inštitut za standardizacijo. Razmnoževanje celote ali delov tega standarda ni dovoljeno.

EUROPEAN PRESTANDARD
ENV 14032
PRÉNORME EUROPÉENNE
EUROPÄISCHE VORNORM
December 2001
ICS 35.240.80
English version
Health Informatics - System of concepts to support nursing
This European Prestandard (ENV) was approved by CEN on 12 January 2001 as a prospective standard for provisional application.
The period of validity of this ENV is limited initially to three years. After two years the members of CEN will be requested to submit their
comments, particularly on the question whether the ENV can be converted into a European Standard.
CEN members are required to announce the existence of this ENV in the same way as for an EN and to make the ENV available promptly
at national level in an appropriate form. It is permissible to keep conflicting national standards in force (in parallel to the ENV) until the final
decision about the possible conversion of the ENV into an EN is reached.
CEN members are the national standards bodies of Austria, Belgium, Czech Republic, Denmark, Finland, France, Germany, Greece,
Iceland, Ireland, Italy, Luxembourg, Netherlands, Norway, Portugal, Spain, Sweden, Switzerland and United Kingdom.
EUROPEAN COMMITTEE FOR STANDARDIZATION
COMITÉ EUROPÉEN DE NORMALISATION
EUROPÄISCHES KOMITEE FÜR NORMUNG
Management Centre: rue de Stassart, 36  B-1050 Brussels
© 2001 CEN All rights of exploitation in any form and by any means reserved Ref. No. ENV 14032:2001 E
worldwide for CEN national Members.

CONTENTS
FOREWORD.3
INTRODUCTION .3
1. SCOPE.4
1.1 MAIN PURPOSES .4
1.2 TARGET GROUPS OF THIS EUROPEAN PRESTANDARD.5
1.3 TOPICS CONSIDERED OUTSIDE THE SCOPE OF THIS EUROPEAN PRESTANDARD.5
2. NORMATIVE REFERENCES.6
3. DEFINITIONS AND CONVENTIONS USED IN DIAGRAMS.6
3.1 DEFINITIONS.6
3.2 CONVENTIONS USED IN DIAGRAMS .8
....................................10
4. SYSTEM OF CONCEPTS FOR NURSING DIAGNOSES
4.1 GENERAL.10
4.2 CATEGORIAL STRUCTURE FOR THE FOCUS OF A NURSING DIAGNOSIS .11
4.3 CATEGORIAL STRUCTURE FOR NURSING DIAGNOSES .12
4.4 ADDITIONAL STATUS QUALIFIERS FOR NURSING DIAGNOSES .14
5. SYSTEM OF CONCEPTS FOR NURSING ACTIONS.15
5.1 GENERAL.15
5.2 CATEGORIAL STRUCTURE FOR NURSING ACTIONS .15
5.3 ADDITIONAL STATUS QUALIFIERS FOR NURSING ACTIONS.17
ANNEX A (INFORMATIVE). INFORMAL DESCRIPTIONS ON CATEGORIES
AND DOMAINS.19
ANNEX B (INFORMATIVE). EXAMPLES OF DISSECTIONS ON NURSING
DIAGNOSES .25
ANNEX C (INFORMATIVE). EXAMPLES OF DISSECTIONS ON NURSING
ACTIONS .29
ANNEX D (INFORMATIVE). HOW TO READ THE DIAGRAMS .34
D.1 INTRODUCTION .34
D.2 CLASSES.34
D.3 ASSOCIATIONS BETWEEN CLASSES .34
D.4 SPECIALISATION AND ABSTRACT CLASSES .34
Foreword
This draft European Prestandard has been prepared by Working group 2 "Terminology and knowledge bases" of
CEN/TC 251 "Health Informatics", the secretariat of which is held by SIS. It is a continuation by a voluntary task
force of the work initiated as a Short Strategic Study entitled "Systems of concepts for nursing: a strategy for
progress" produced under mandate M/255 given to CEN by the European Commission and the European Free
Trade Association, order voucher BC/CEN/97/23.6.
All Annexes are informative.
According to the CEN/CENELEC Internal Regulations, the national standards organizations of the following
countries are bound to announce this European Prestandard: Austria, Belgium, Czech Republic, Denmark,
Finland, France, Germany, Greece, Iceland, Ireland, Italy, Luxembourg, Netherlands, Norway, Portugal, Spain,
Sweden, Switzerland and the United Kingdom.
Introduction
Terminology models and categorial structures deal with the essential structure for concept systems.
This Prestandard aims at facilitating the process of harmonisation across terminological systems on nursing
diagnoses and nursing actions, by reducing unnecessary diversity and making explicit motivated diversity. It also
aims at assisting integration of terminology systems within health records and other healthcare applications, and
at establishing a continuum between information models and terminology models. Moreover, developers of
terminology systems may use this standard for systematic presentation (i.e. to build taxonomies), to reduce
ambiguities in the expressions, to produce more systematic descriptions.
Robust categorial structures can only be obtained by performing mapping from the various existing systems (and
from real charts), putting them into a database or a description-logic system, and studying deeply the problems
arising from these mappings. To perform this activity on a large scale, a consolidated hypothesis is needed.
The presence of the ENV allows experiments and validations to be concentrated on a precise hypothesis, so
that contributions will be focussed and the evolution towards the final normative content will be effective.
The textual description of the Prestandard is accompanied by a set of tables providing synopses of categorial
structures for the focus of nursing diagnoses (see Subclause 4.2), for nursing diagnoses (see Subclause 4.3),
and for nursing actions (see Subclause 5.2). It should be noted that any examples given in the Prestandard are
non-exhaustive. Graphical outlines (according to the UML conventions, see Subclause 3.2 and Annex D) of the
system of concepts for nursing diagnoses and nursing actions are provided in figures 1 and 2.
The normative part is complemented by 4 informative Annexes.
Annex A provides informal descriptions of the domains and categories in the Prestandard. These are informative
content, intended to clarify the meaning and scope of each item through the use of descriptions and non-
exhaustive examples – they are not normative definitions.
Annex B lists examples of dissections on nursing diagnoses and Annex C on nursing actions.
Annex D provides a synthesis of the UML conventions.
1. SCOPE
1.1 Main purposes
This European Prestandard describes a system of concepts to support the development, maintenance,
comparison and implementation of terminology systems, which in turn support data classification,
communication, storage and retrieval in Nursing Information Systems and Nursing Records. This European
Prestandard includes a set of categorial structures that cover nursing diagnoses and nursing actions.
Even though the Prestandard is centered on nursing needs, it may be used for domains with similar semantic
properties, such as the subject field covered by ICIDH-2.
The main uses foreseen for the system of concepts are to:
- provide a language to highlight the structure and/or the taxonomy of a terminology system, i.e. the most
relevant and systematic criteria used by developers to organise the terminology system. This description
may be used to harmonise a terminology system within the environment of an information system, e.g. by
comparing information models and terminology models.
- provide the criteria to generate systematic names from rubrics and terms of a terminology system, as a
supporting feature to be distributed in the near future together with the usual presentation of the terminology
system itself.
The provisions of this European Prestandard apply to the complete, contextualised meaning of the terms and will
not apply directly to the surface/literal expressions of preferred terms or working terms registered in existing
terminology systems. Often, relevant details pertaining to a term can only be understood from its context within
the terminology system. Therefore, it is recommended that terms be paraphrased to reflect contextualised
meaning before applying this European Prestandard.
Definitions or free text descriptions of these terms contain many pragmatic or assertional concepts (e.g. defining
characteristics of nursing diagnoses) that are outside the scope of the present system of concepts.
The content of this European Prestandard is not intended to be used as a terminology system for end-users.
Systematic representation according to this Prestandard is not intended to replace the original rubric or the
original expression from the coding system or terminology to which it is applied.
Actual descriptors — together with the style and the symbols for the systematic representation — are outside the
scope of this standard. They will be defined by the organisations producing the representations. After trial
implementations of this Prestandard, a harmonised set of descriptors could be considered for inclusion in a
future revision of this Prestandard.
The scope of this Prestandard is limited to the unambiguous representation of the terminological entries. Similar
concepts may have different valid representations according to this Prestandard. It is out of the scope of this
Prestandard to provide normalisation rules to compare two representations and to establish their equivalence.
It is outside the scope of this Prestandard, to define provisions about the nature and content of the guidelines for
the management of status qualifiers (see Subclauses 4.4 and 5.3).
Categorial structures can be used to support different ways of implementing a terminology system. For example:
1. pre-coordinated terms. One data field in an information system contains a term or term phrase that may
represent a systematic combination of concepts. Often this term or term phrase has a predefined non-
combinatorial code, e.g. (from NIC) 6408 “Abuse protection support: religious”.
2. post-coordinated terms. One field in an information system contains a combination of terms (or codes),
created by the user according to predefined rules, e.g. the user’s expression: “moderate restriction in
participation in parent-child relationships” may be represented in ICIDH-2 by the following two terms:
“participation in parent-child relationships” + “moderate restriction”
3. name-value pairs. An entry in an information system may be made up of two fields: one field for a term
or term phrase to represent the variable that is observed and one field for the corresponding value. The
value can be a numeric value, a score, a qualitative scale, a binary value, a coded value.
4. data sets made of a predefined list of names for the variables to be observed, e.g. assessment
templates. At instantiation, the user assigns a value to each variable.
Each of the various categories and qualifiers described in this Prestandard may therefore appear either as part
of a pre-coordinated term, as part of one of the multiple post-coordinated terms, as part of the names of the
variables, or as part of the values. This Prestandard is not precluding any of these solutions or recommending
one particular subdivision, except the ones on status qualifiers described in Subclauses 4.4 and 5.3.
The provisions of this European Prestandard partially apply to classes used to structure terminologies (e.g.
“Heart functions” in ICIDH-2). The terms that represent these classes are too generic to be used alone in nursing
records — i.e. to describe in detail the nursing diagnosis or the nursing action — but they obey the same
semantic rules as the more detailed terms.
1.2 Target groups of this European Prestandard
This European Prestandard is for use by
a) developers of coding systems and terminologies on nursing, to assist in the development and
maintenance of a particular system, as well for comparisons among different systems;
b) developers of categorial structures about other systems of concepts, to take into account the relation
with nursing and to be aware of the overlaps among different subject fields;
c) information modellers and knowledge engineers building models for record systems, in particular to
describe the expected content of terminological value domains for particular attributes and data
elements;
d) developers of information systems which need to handle an explicit system of clinical concepts for
internal organization, datawarehouse management and middleware services;
e) developers of software for Natural Language Processing, to facilitate harmonisation of their output with
coding systems and record structures;
f) developers of markup standards for representation of healthcare documents.
1.3 Topics considered outside the scope of this European Prestandard
This European Prestandard is not intended to provide
a) a detailed classification or nomenclature on nursing diagnoses or nursing actions;
b) descriptors and guidelines to represent contextual information for the recording of information within an
electronic healthcare record;
c) an exhaustive list of all the potential details that could appear in expressions of nursing diagnoses and
nursing actions;
d) an exhaustive thesaurus with the complete list of descriptors to be used to describe nursing diagnoses
and nursing actions.
2. NORMATIVE REFERENCES
This European Prestandard incorporates by dated or undated reference, provisions from other publications.
These normative references are cited in the appropriate places in the text, and the publications are listed
hereafter. For dated references, subsequent amendments and revisions of any of these publications apply to this
European Prestandard only when incorporated in it by amendment and revision. For undated references, the
latest edition of the publication referred to applies (including amendments).
ENV 12264:1997 Medical Informatics — Categorial structure of systems of concepts — Model for
representation of semantics
ENV 1614:1995 Medical informatics — Structure for nomenclature, classification and coding of
properties in clinical laboratory sciences
3. DEFINITIONS AND CONVENTIONS USED IN DIAGRAMS
3.1 Definitions
For the purposes of this standard, the following definitions apply:
3.1.1 associate (semantic) category
semantic category standing for a set of associate concepts  [ENV 12264]
EXAMPLE: stands for the set of associate concepts following the semantic link “has means”
that describe the instruments, equipment or tools used to accomplish a nursing action.
3.1.2 associate concept
concept which follows a semantic link [ENV 12264, modified]
EXAMPLE: "patient", following the semantic link “has beneficiary” in a system of concepts on nursing
action.
3.1.3 associate (semantic) domain
semantic domain standing for a set of associate categories
EXAMPLE: in this Prestandard, the semantic link “is applied to” defines an associate domain (called the
<>) including associate categories such as , .
NOTE: the name of an associate domain often reflects the name of the corresponding semantic link, e.g.
“has means” <>, “has beneficiary” <>.
3.1.4 base (semantic) category
semantic category standing for a set of base concepts [ENV 12264]
EXAMPLE: , which indicates sufficiency for a particular requirement, in a system of
concepts on nursing diagnoses.
3.1.5 base concept
concept used systematically as superordinate concept in dissections of target concepts [ENV 12264, modified]
EXAMPLE: the descriptor "informing" can be used systematically in dissections that describe the target
concepts of nursing actions about provision of information to patients or relatives. All these target
concepts are children of “informing”.
3.1.6 base (semantic) domain
semantic domain standing for a set of base categories
EXAMPLE: <>, which represents the set of base categories for a nursing diagnosis, such
as or .
3.1.7 categorial structure
reduced system of concepts to describe the essential organization of the semantic categories in a particular
system of concepts for development, maintenance and application of terminology systems [ENV 12264,
modified]
3.1.8 descriptor
concept considered as elementary for usage in a set of dissections
EXAMPLE: “bathing” is a descriptor belonging to the semantic category
NOTE 1: a descriptor (e.g. “bathing oneself”, see Annex B, example 5) may be considered as
elementary for a set of dissections corresponding to a coding system, but the same concept may be
expressed by multiple descriptors for another coding system, i.e. according to different systematisation
needs.
NOTE 2: a descriptor can appear only in one category, but it can be used in multiple semantic domains.
3.1.9 differentiating criterion
semantic link and an associate category
NOTE: differentiating criteria are used to build taxonomies. If an associate semantic domain is involved
in the creation of a new layer of a taxonomy, the corresponding differentiating criteria may generate
subtrees with different structures. E.g. in a coding system of nursing actions, if a layer of the taxonomy is
built according to the semantic link “has means”, then three independent subtrees may be generated,
i.e. one based on the differentiating criterion “has means”-, one based on the differentiating
criterion “has means”-, and one based on the differentiating criterion “has means”-
. In fact, the three internal categorial structures respectively of , and
may involve a different organisation of the subsequent layers of the respective sub-
taxonomies.
3.1.10 dissection
systematic representation of a phrase according to a predefined categorial structure
3.1.11 qualifier
concept used to further specify another concept
EXAMPLE: the qualifier “risk for” further specifies a nursing diagnosis
NOTE: the names for the semantic categories of qualifiers usually are similar to the corresponding
semantic link (e.g. “has existence qualifier”-, “has evolution qualifier”-, has
success qualifier”-).
3.1.12 (semantic) category
concept chosen to stand for a specified set of subordinate concepts, considered homogeneous [ENV 12264]
EXAMPLES: , , ,
NOTE 1: In examples within this Prestandard, semantic categories are enclosed in angle brackets < >.
NOTE 2: a descriptor can appear only in one category.
3.1.13 (semantic) domain
set of semantic categories taking the same role in a system of concepts
EXAMPLES: <>, <>, <>
NOTE 1: In examples within this Prestandard, semantic domains are enclosed in double angle brackets
<< >>.
NOTE 2: a semantic category may appear in different semantic domains, e.g. can be a
<>, a <>, a <>. Therefore a descriptor may belong to multiple domains
(but only to one semantic category) and the same descriptor can be present in one dissection with
different roles, i.e. it may correspond to different semantic domains (e.g. a “patient” can be the direct
<> and the final <> for a nursing action).
3.1.14 (semantic) link
unidirectional associative relation from one concept to another  [ENV 12264, modified]
EXAMPLE: the semantic link “has-site” could be applied from the concept "pain" to the concept "hip", in
a system of concepts to describe nursing diagnoses.
NOTE: A semantic link may be also used between semantic categories and semantic domains.
3.1.15 system of concepts
structured set of concepts established according to the relations between them [ENV 12264]
NOTE: A system of concepts is wider than a categorial structure. For example it may include categories
and semantic links for status qualifiers (see Subclauses 4.4 and 5.3) and multiple categorial structures
(see Subclauses 4.2 and 4.3).
3.1.16 systematic name
terminological phrase created according to preestablished rules and used as name for a target concept [ENV
12264]
NOTE 1: In common practice, a working name can be used in place of the systematic name. The
working name may be either a term or a simpler terminological phrase.
NOTE 2: systematic names are the bridge between working names (e.g. expressions from
nomenclatures, for humans) and formal representations (e.g. dissections, for computers)
3.1.17 target concept
concept whose designation is intended to be used in applications [ENV 12264]
EXAMPLE: "teach patient about diabetes" could be a target concept for nursing actions in a nursing
record application. The concepts: “monitoring”, “teach relatives” are usually considered incomplete in
that context and therefore cannot be considered adequate as target concepts.
3.2 Conventions used in diagrams
The textual description of the categorial structures in the Prestandard is accompanied by graphical outlines,
drawn according to UML conventions (see Annex D, informative).
The correspondence between the UML constructs for information models and the terminological constructs for a
system of concepts is as follows:

The labeled lines in the figures represent semantic links. Direction is implied by the position of the label.

The labels in the upper compartment of the boxes represent either semantic categories or semantic
domains.

Semantic domains are considered as abstract classes of UML and their labels are italicised in the diagrams.
They are enclosed in double angle brackets << >> throughout the document.

Semantic categories are considered as instantiable classes in UML and their labels are in plain font in the
diagrams. They are enclosed in angle brackets < > throughout the document

Qualifiers are considered as the attributes in UML and appear in the middle compartment of the boxes.

The lower compartment of the boxes is not used.
4. SYSTEM OF CONCEPTS FOR NURSING DIAGNOSES
4.1 General
For the purposes of this Prestandard, a nursing diagnosis shall be considered either as a judgement on
something (called focus) or as a judgement on a particular dimension (e.g. ability, knowledge) of something.
The categories , and are a special case of nursing
diagnosis as they may contain both judgement and focus (see Note 1 in Subclause 4.3).
The categorial structure for the focus of a nursing diagnosis is described in Subclause 4.2.
The categorial structure for nursing diagnoses is described in Subclause 4.3.
Additional qualifiers that should be used mainly within patient records — rather than within terminological
expressions of nursing diagnoses — are described in Subclause 4.4.
All categories and domains are informally described in Annex A (informative).
A comprehensive graphical outline of the system of concepts for nursing diagnoses is presented in figure 1.
dimension
is perspective on
is applied to
focus judgement
is applied to
degree
timing
potentiality
has site
acuity
timing
has bearer
is associated with
site
bearer
Figure 1. Graphical outline of the system of concepts for nursing diagnoses
4.2 Categorial structure for the focus of a nursing diagnosis
The categorial structure for the focus of nursing diagnoses is described in detail in this Subclause and is
summarised in table 1.
Developers of a terminology system on <> of nursing diagnoses shall complement their system with
supporting documentation, showing how each rubric or code can be unambiguously represented according to
the provisions of this Subclause.
Extension of the current categorial structure (i.e. the adoption of new categories and new semantic links) is
allowed. It should be carefully documented and shall not be in conflict with the provisions of this Prestandard, in
particular with exclusions stated in Subclause 4.4.
A comprehensive list of descriptors, divided by semantic category and possibly organised into a taxonomy,
should also be provided. Descriptors that are to be considered as defaults, should be clearly stated in the
supporting documentation provided by the developers of the terminology system.
The <> of a nursing diagnosis may be, for example, a , a , a , or
a . The category of shall be used according to the Prestandard ENV 1614. The categories
, , are special cases - see Note 1, Subclause 4.3.
The <> may refer to a <>. This can be a , an (e.g. a wound)
a , or a part of one of these. The <> may be further qualified e.g. by one or more spatial qualifiers
that express a , as appropriate.
The <> may be qualified by a temporal qualifier on .
NOTE 1. The focus is a crucial component of any expression about diagnoses. In practice, nurses
centre their observations on the focus, in order to make a judgement. Diagnoses are often organised
according to the focus when building user-friendly interfaces, and when structuring assessment
templates. The hierarchy on the focus is often used to organise the presentation of terminology systems
(see for example ICIDH-2).
Table 1 – SYNOPSIS OF THE CATEGORIAL STRUCTURE FOR THE FOCUS OF NURSING DIAGNOSES
base domain non-exhaustive examples of base categories
<> , , , ,
, , (see note 1, Subclause 4.3)
differentiating criteria
semantic links Non-exhaustive examples of associate categories/associate domains
has site <>, including , ,
(may be further qualified by: has spatial qualifier )
has temporal qualifier
4.3 Categorial structure for nursing diagnoses
The categorial structure for nursing diagnoses is described in this Subclause, and is summarised in table 2.
Developers of a terminology system on nursing diagnoses shall complement their system with supporting
documentation, showing how each rubric or code can be unambiguously represented according to the provisions
of this Subclause.
Extension of the current categorial structure (i.e. the adoption of new categories and new semantic links) is
allowed. It should be carefully documented and shall not be in conflict with the provisions of this Prestandard, in
particular with exclusions stated in Subclause 4.4.
A comprehensive list of descriptors, divided by semantic category and possibly organised into a taxonomy,
should also be provided. Descriptors that are to be considered as defaults, should be clearly stated in the
supporting documentation provided by the developers of the terminology system.
Categorial structures can be nested, and therefore the categorial structure for nursing diagnoses is built around
the one on <>.
One descriptor on <> is mandatory for each expression enumerated in a terminology system on
nursing diagnoses. A <> may be, for example, , or . It may be also an
or an or an (see note 1 below).
NOTE 1: The categories , , are special cases in
which the <> and the <> are pre-coordinated. For example, anxiety, pain, pressure
sore, wound. For these categories, the applicable provisions about both <> and <>
are valid and one descriptor satisfies the provisions for both domains.
According to the style of the representation adopted in relation to a particular terminology system, the descriptors
for <> may be expressed either as adjectives or as nouns.
One descriptor about the <> is mandatory for each expression enumerated in a terminology system on
nursing diagnoses. According to the expression involved, it can be either directly linked to the <> by
the semantic link “is applied to”, or it can be linked indirectly through the semantic link “is applied to”, followed by
a descriptor of and by a semantic link “is perspective on”.
EXAMPLE 1: In the dissection
“alteration – is applied to – temperature”,
the <> (i.e. alteration) is linked directly to the <> (i.e. temperature) by the link “is
applied to”. In the dissection
“inadequate – is applied to – knowledge – is perspective on – breastfeeding”,
the <> (i.e. inadequate) is linked to the <> (i.e. breastfeeding) indirectly, i.e. through
a descriptor for (i.e. knowledge) and the two related links.
The can also be a perspective on a nursing diagnosis, with or without its status qualifiers (see
Subclause 4.4).
EXAMPLE 2: “inadequate knowledge about hypertension”, “lack of awareness about possible presence
of cancer”.
NOTE 2: for simplicity, the above link is not represented in the graphical outline in figure 1.
A term phrase may contain an expression on nursing diagnosis associated with another expression on nursing
diagnosis. In the related dissection, the <> will be associated with another <>. This
allows nesting of nursing diagnoses without limiting the nature of the link to for example, causality. This kind of
recursion is guided by the expression that is being represented; it does not create an infinite loop. The associate
nursing diagnosis may be qualified by the status qualifiers listed in Subclause 4.4.
NOTE 3. This Prestandard accommodates the expression of causality within a nomenclature, e.g. when
a generic cause is relevant in the description of the patient’s state (e.g. “traumatic”). In practice, due to
the large number of combinations that are often involved in the description of the cause, it is more likely
that detail on causality will not be expressed within the terminology system for nursing diagnoses, but by
more flexible mechanisms in a nursing record, e.g by an explicit link between two existing data items, or
within a predefined cluster that systematically associates a data item for the diagnosis with a data item
for the cause.
The <> pertains to a <>, which may be either an (e.g. the patient or a family
member), a (e.g. the family as a whole) or the . The descriptor “client” or
“patient” shall be considered as the default value for the <>. Nevertheless, it shall be made explicit,
when similar rubrics in the terminology system apply to different bearers, i.e. the <> shall not be
ambiguous.
NOTE 4: The bearer is the “subject of information” (i.e. the individual or group to which the information
refers), and may be different from the “subject of care” (i.e. the patient or the group under treatment). For
example, the subject of information involved in the diagnosis may be a relative of the actual patient.
The <> may be qualified by at most one descriptor for (e.g. mild) and at most one
descriptor for  (e.g. risk for, actual). The descriptor “actual” shall be the default value for
. Nevertheless, it shall be explicit, when other similar rubrics in the coding system use different
values for , i.e. the shall not be ambiguous.
The <> may be qualified by temporal qualifiers on (e.g. chronic) and (e.g. post-
operative). At most one descriptor is allowed for each type of temporal qualifier.
NOTE 5: For the purposes of this standard, the base for a nursing diagnosis is considered to be
judgement. According to the definition of a base domain, the descriptor of judgement is the
superordinate concept for any valid expression on nursing diagnosis.
This could be used to guide the building of hierarchies of nursing diagnoses, for example:
judgement on body temperature
alteration in body temperature
increase in body temperature
moderate increase in body temperature
Table 2 - SYNOPSIS OF THE CATEGORIAL STRUCTURE FOR NURSING DIAGNOSES
base domain non-exhaustive examples of base categories
judgement , ,
, , (see note 1, Subclause 4.3)
differentiating criteria
semantic links non-exhaustive examples of associate categories/associate domains
is applied to <> (see Subclause 4.2)
(in turn, “is perspective on” either <>, or nursing
diagnosis with or without status qualifiers (see Subclause 4.4))
is associated with nursing diagnosis with or without status qualifiers (see Subclause 4.4)
has bearer <>, including , ,
has gradation qualifier
has potentiality qualifier
has temporal qualifier ,
4.4 Additional status qualifiers for nursing diagnoses
For the purpose of this standard, a statement about nursing diagnosis should be represented in a patient record
by two separate components:
1. a terminological kernel containing the nursing diagnosis proper, without reference to its existence (e.g.
present, absent), process state (e.g. former, ongoing, terminated), evolution (e.g. increasing, improving),
uncertainty (e.g. possible, certain), knowing mode (e.g. reported, hypothesised), frequency (e.g. at
regular intervals, often), or temporal pattern (e.g. intermittent, continuous);
2. a set of status qualifiers, putting the terminological kernel in the context of a patient record.
Subclause 4.3 deals with the terminology systems that describe the terminological kernel. This Subclause deals
with the status qualifiers.
In principle, rubrics and terms about nursing diagnoses — enumerated in a terminology system — should not
refer to the status qualifiers listed in table 3, which should be instead enumerated within separate value sets.
Status qualifiers may be included in the terminological kernel only in the two cases specified in Subclause 4.3:
1.  “is perspective on” nursing diagnosis, with or without status qualifiers
2. <> “is associated with” nursing diagnosis, with or without status qualifiers
Exceptions are allowed when the qualifier is essential to the expression involved.
Within a patient record, the status qualifiers should appear as additional data items with respect to the data item
for the nursing diagnosis, and they should be used only for post-coordination. Developers of terminology
systems should provide suitable guidelines to their users, about the mechanism to link the status qualifiers to the
rubrics and terms on nursing diagnoses.
NOTE: It is out of the scope of this Prestandard, to systematise the narrative about nursing diagnoses,
including defining characteristics and links to etiology, goals, interventions, outcomes, etc. Links
between these constructs are formed in the patient record according to relationships defined in an
information model.
Table 3 – Status qualifiers that may be post-coordinated to expressions on nursing diagnoses
semantic links associate categories
has existence qualifier
has state qualifier
has evolution qualifier
has uncertainty qualifier
has knowing qualifier
has temporal qualifier ,
5. SYSTEM OF CONCEPTS FOR NURSING ACTIONS
5.1 General
The categorial structure for nursing actions is described in Subclause 5.2.
Some additional qualifiers that pertain mainly to the patient record and should be avoided within expressions on
nursing actions are described in Subclause 5.3.
All categories and domains are informally decribed in Annex A (informative).
A comprehensive graphical outline of the system of concepts for nursing actions is presented in figure 2.
is associated with
has site
action
site
timing target
acts on
has route
has beneficiary
has means
route
beneficiary
means
Figure 2. Graphical outline of the system of concepts for nursing actions
5.2 Categorial structure for nursing actions
The categorial structure for nursing actions is described in this Subclause and summarised in table 4.
Developers of a terminology system on nursing actions shall complement it with supporting documentation,
showing how each rubric or code can be unambiguously represented according to the provisions of this
Subclause.
Extension of the current categorial structure (i.e. the adoption of new categories and new semantic links) is
allowed. It should be carefully documented and shall not be in conflict with the provisions of this Prestandard, in
particular with exclusions stated in Subclause 5.3.
A comprehensive list of descriptors, divided by semantic category and possibly organised into a taxonomy,
should also be provided. Descriptors that are to be considered as defaults, should be clearly stated in the
supporting documentation provided by the developers of the terminology system. Developers of the set of
descriptors are responsible for avoiding ambiguities. For example, a descriptor “protecting” could be
misunderstood when processing the expression "protecting abuse". Therefore the descriptor could be "protecting
from".
One descriptor on is mandatory for each expression enumerated in a terminology system on nursing
actions.
An "acts on" something, called a <>.
A <> may be, for example, (or part of it, e.g. a lobe of the liver), , (or
part of it, e.g. a balloon of a catheter), , , , ,
, , . In addition, a <> may be also any one of the categories that may
take the role of <> of a nursing diagnosis (see Subclause 4.2), it may be a whole nursing diagnosis (see
Subclause 4.3) with or without its status qualifiers (see Subclause 4.4), or it may be a whole nursing action with
or without its status qualifiers (see Subclause 5.3).
EXAMPLE 1: Nursing actions as <> may be found in Annex C, examples # 9, 10, 18, 19, 21,
24, 25, 29, 36.
One descriptor about the <> is mandatory for each expression enumerated in a terminology system on
nursing actions.
An may be linked to another , using the semantic link “is associated with”. The chain of
can be as long as needed by the expression that is being represented. This kind of recursion is guided
by the expression that is being represented; it does not create an infinite loop. Each action has its own
<> and <>. The associated can be with or without its status qualifiers (see
Subclause 5.3).
EXAMPLE 2: Preventing decubitus by positioning patient
preventing
acts on decubitus
has beneficiary patient
is associated with positioning
acts on patient
has beneficiary patient
Note the roles of “patient” in the different contexts of this dissection. Additional examples of nursing
actions following the semantic link “is associated with” are included in Annex C, examples # 26, 27, 35.
The has a <>, i.e. the recipient of the final benefit. It may be either an (e.g.
the patient or a family member) or a (e.g. the family as a whole). The descriptor “client” shall be
considered as the default value for the beneficiary. Nevertheless, it shall be explicit, when similar rubrics in the
terminology system apply to different beneficiaries, i.e. the <> shall not be ambiguous.
The same descriptor can appear both as direct <> of the action and as final <> of the
same action.
EXAMPLE 3: In the expression ”teaching patient” the patient is both target and beneficiary. In the
expression ”teaching relative” the target is the relative and the beneficiary may be the patient.
See also Example 2.
The may refer to a <>, as the , , or indirectly
involved in the action. The <> may be further specified, e.g. by one or more spatial qualifiers that express
a , as appropriate.
An may refer to a <>, which may be, for example, a , a or a
.
An may also refer to a .
The may be qualified by a temporal qualifier on . At most one descriptor is allowed for this
qualifier.
Table 4 - Synopsis of the categorial structure for nursing actions
base category

differentiating criteria
semantic links non-exhaustive examples of associate categories/associate domains
acts on <>, including , , , ,
, ,  (see note 1, Subclause 4.3),
, , , , , ,
, , , ,
nursing diagnosis with or without status qualifiers (see Subclause 4.4)
nursing action with or without status qualifiers (see Subclause 5.3)
is associated with with or witho
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