EN ISO 18104:2014

SLOVENSKI STANDARD
01-julij-2014
1DGRPHãþD
SIST EN ISO 18104:2004
Zdravstvena informatika - Kategorijske strukture za predstavitev diagnoz in
postopkov bolniške nege v terminoloških sistemih (ISO 18104:2014)
Health informatics - Categorical structures for representation of nursing diagnoses and
nursing actions in terminological systems (ISO 18104:2014)
Medizinische Informatik - Kategoriale Strukturen zur Darstellung von Pflegediagnosen
und Pflegeaktionen in terminologischen Systemen (ISO 18104:2014)
Informatique de santé - Structures catégoriques pour la représentation des diagnostics
de soins et des actions de soins dans les systèmes terminologiques (ISO 18104:2014)
Ta slovenski standard je istoveten z: EN ISO 18104:2014
ICS:
11.020 0HGLFLQVNHYHGHLQ Medical sciences and health
]GUDYVWYHQRYDUVWYHQL care facilities in general
SULSRPRþNLQDVSORãQR
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 STANDARD
EN ISO 18104
NORME EUROPÉENNE
EUROPÄISCHE NORM
February 2014
ICS 35.240.80 Supersedes EN ISO 18104:2003
English Version
Health informatics - Categorial structures for representation of
nursing diagnoses and nursing actions in terminological systems
(ISO 18104:2014)
Informatique de santé - Structures catégoriques pour la Medizinische Informatik - Strukturen zur Darstellung von
représentation des diagnostics de soins et des actions de Pflegediagnosen und Pflegeaktionen in terminologischen
soins dans les systèmes terminologiques (ISO 18104:2014) Systemen (ISO 18104:2014)
This European Standard was approved by CEN on 4 January 2014.

CEN members are bound to comply with the CEN/CENELEC Internal Regulations which stipulate the conditions for giving this European
Standard the status of a national standard without any alteration. Up-to-date lists and bibliographical references concerning such national
standards may be obtained on application to the CEN-CENELEC Management Centre or to any CEN member.

This European Standard exists in three official versions (English, French, German). A version in any other language made by translation
under the responsibility of a CEN member into its own language and notified to the CEN-CENELEC Management Centre has the same
status as the official versions.

CEN members are the national standards bodies of Austria, Belgium, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia,
Finland, Former Yugoslav Republic of Macedonia, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Latvia, Lithuania,
Luxembourg, Malta, Netherlands, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, Switzerland, Turkey and United
Kingdom.
EUROPEAN COMMITTEE FOR STANDARDIZATION
COMITÉ EUROPÉEN DE NORMALISATION

EUROPÄISCHES KOMITEE FÜR NORMUNG

CEN-CENELEC Management Centre: Avenue Marnix 17, B-1000 Brussels
© 2014 CEN All rights of exploitation in any form and by any means reserved Ref. No. EN ISO 18104:2014 E
worldwide for CEN national Members.

Contents Page
Foreword .3

Foreword
This document (EN ISO 18104:2014) has been prepared by Technical Committee ISO/TC 215 “Health
informatics” in collaboration with Technical Committee CEN/TC 251 “Health informatics” the secretariat of
which is held by NEN.
This European Standard shall be given the status of a national standard, either by publication of an identical
text or by endorsement, at the latest by August 2014, and conflicting national standards shall be withdrawn at
the latest by August 2014.
Attention is drawn to the possibility that some of the elements of this document may be the subject of patent
rights. CEN [and/or CENELEC] shall not be held responsible for identifying any or all such patent rights.
This document supersedes EN ISO 18104:2003.
According to the CEN-CENELEC Internal Regulations, the national standards organizations of the following
countries are bound to implement this European Standard: Austria, Belgium, Bulgaria, Croatia, Cyprus, Czech
Republic, Denmark, Estonia, Finland, Former Yugoslav Republic of Macedonia, France, Germany, Greece,
Hungary, Iceland, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, Netherlands, Norway, Poland, Portugal,
Romania, Slovakia, Slovenia, Spain, Sweden, Switzerland, Turkey and the United Kingdom.
Endorsement notice
The text of ISO 18104:2014 has been approved by CEN as EN ISO 18104:2014 without any modification.
INTERNATIONAL ISO
STANDARD 18104
Second edition
2014-02-01
Health informatics — Categorial
structures for representation of
nursing diagnoses and nursing actions
in terminological systems
Informatique de santé — Structures catégoriques pour la
représentation des diagnostics de soins et des actions de soins dans les
systèmes terminologiques
Reference number
ISO 18104:2014(E)
©
ISO 2014
ISO 18104:2014(E)
© ISO 2014
All rights reserved. Unless otherwise specified, no part of this publication may be reproduced or utilized otherwise in any form
or by any means, electronic or mechanical, including photocopying, or posting on the internet or an intranet, without prior
written permission. Permission can be requested from either ISO at the address below or ISO’s member body in the country of
the requester.
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Published in Switzerland
ii © ISO 2014 – All rights reserved

ISO 18104:2014(E)
Contents Page
Foreword .iv
Introduction .v
1 Scope . 1
2 Normative references . 2
3 Terms and definitions . 2
3.1 General . 2
3.2 Categories of healthcare entities for nursing diagnoses . 4
3.3 List of authorized representation relations for nursing diagnoses . 5
3.4 Categories of healthcare entities for nursing actions . 6
3.5 List of authorized representation relations for nursing actions . 7
4 Categorial structures — Conformance principles . 7
5 Categorial structure for representing nursing diagnoses . 8
6 Categorial structure for representing nursing actions . 9
Annex A (informative) Summary of changes to ISO 18104:2003 .11
Annex B (informative) Nursing diagnosis and nursing actions in context .17
Annex C (informative) Guidance notes for using categorial structures .24
Bibliography .28
ISO 18104:2014(E)
Foreword
ISO (the International Organization for Standardization) is a worldwide federation of national standards
bodies (ISO member bodies). The work of preparing International Standards is normally carried out
through ISO technical committees. Each member body interested in a subject for which a technical
committee has been established has the right to be represented on that committee. International
organizations, governmental and non-governmental, in liaison with ISO, also take part in the work.
ISO collaborates closely with the International Electrotechnical Commission (IEC) on all matters of
electrotechnical standardization.
The procedures used to develop this document and those intended for its further maintenance are
described in the ISO/IEC Directives, Part 1. In particular the different approval criteria needed for the
different types of ISO documents should be noted. This document was drafted in accordance with the
editorial rules of the ISO/IEC Directives, Part 2. www.iso.org/directives
Attention is drawn to the possibility that some of the elements of this document may be the subject of
patent rights. ISO shall not be held responsible for identifying any or all such patent rights. Details of any
patent rights identified during the development of the document will be in the Introduction and/or on
the ISO list of patent declarations received. www.iso.org/patents
Any trade name used in this document is information given for the convenience of users and does not
constitute an endorsement.
For an explanation on the meaning of ISO specific terms and expressions related to conformity
assessment, as well as information about ISO’s adherence to the WTO principles in the Technical
Barriers to Trade (TBT) see the following URL: Foreword - Supplementary information
The committee responsible for this document is ISO/TC 215, Health informatics.
This second edition cancels and replaces the first edition (ISO 18104:2003), which has been technically
revised. For the history of the revision and a summary of the changes, see the Introduction and Annex A.
iv © ISO 2014 – All rights reserved

ISO 18104:2014(E)
Introduction
Development of terminological systems (also referred to as terminologies) to support nursing has been
motivated by multiple factors including the need to
— describe nursing in order to educate and inform students and others,
— represent nursing concepts in electronic systems and communications, including systems that
support multiprofessional team communications and personal health records, and
— analyse data about the nursing contribution to patient care and outcomes — for quality improvement,
research, management, reimbursement, policy and other purposes.
Multiple terminologies exist to support representation of concepts for healthcare purposes; some of
these are relevant to the nursing domain. In the context of health informatics, there is a clear requirement
for both domain coverage and for interoperability among computer-processable terminological systems
that support nursing. Nursing terminologies, or those parts of healthcare-related terminologies that are
relevant to nursing, include concept representations for nursing diagnoses and nursing actions.
A nursing diagnosis is a label assigned to an assessment finding, event, situation or other health issue
to indicate that it is considered to be noteworthy by the nurse and, where possible, the subject of care.
Nursing actions are acts performed by or under the direction of a nurse, with the intention of directly
or indirectly improving or maintaining the health of a person, group or population, the precise scope of
nursing actions being delineated in each jurisdiction. These concepts and the scope of nursing practice
are further elaborated in Annex B.
[1]
The first edition of this International Standard focused on the conceptual structures that are the
basis of nursing terminologies in order to support interoperability. A major purpose was “to establish
a nursing reference terminology model consistent with the goals and objectives of other specific health
terminology models in order to provide a more unified reference health model”. This purpose is still
relevant to this revision of the standard, to support interdisciplinary communication, for example,
where single, shared records are used, including records held by patients.
Following ISO rules, a review of ISO 18104:2003 was undertaken during 2008/09; ISO national
member bodies, nursing organisations, industry representatives and experts provided comment. In
addition to evaluation of the purpose, target groups, definitions and provisions of the standard, the
review considered the implications of relevant International Standards published since 2003. The main
findings/recommendations of the review were as follows.
a) The standard was being used in at least 11 member countries and by several international
terminology development organizations.
b) Any revision should be based on a clearly articulated value proposition supported by evidence from
the review. Published examples of use and value are provided in the Bibliography, linked to the
specific purposes stated in Clause 1. There is anecdotal evidence of other uses, including supporting
design of terminology content in electronic record systems.
c) Normative references and definitions to be updated. Other relevant international work needed to
be considered, such as the World Health Organization Family of International Classifications (WHO-
[2]
FIC) International Classification of Healthcare Interventions (ICHI).
d) A review of relevant International Standards confirmed that the naming of some categories might
need to be revised and that some categories could have been more appropriately designated as
semantic links.
e) Responses indicated that “dimension” and “potentiality” in the diagnosis model and “target” in the
action model were not applied reliably by different users and required further consideration.
ISO 18104:2014(E)
f) It was recommended that a model for outcomes be considered and that informative annexes clarify
the relationship between the model for diagnoses and the model for actions, as well as points of
intersection between terminology models and information models.
g) A number of reviewers recommended that the standard be supported by implementation
guidance/examples, and that the title and the language used be revised, so that it would be better
understood by target groups.
This second edition addresses these findings and recommendations. In the main body of the standard,
two redundant categories have been removed (dimension and recipient of care) and changes have been
made to correct errors, clarify meaning and update definitions. Annex A summarizes the changes.
The standard defines the structure of terminological expressions for nursing diagnoses and nursing
actions; the professional meaning of these constructs and their relationship to other record components
is addressed in Annex B along with points of intersection between terminology models and information
models. An informative description of categorial structures and their implementation is provided by
Annex C.
vi © ISO 2014 – All rights reserved

INTERNATIONAL STANDARD ISO 18104:2014(E)
Health informatics — Categorial structures for
representation of nursing diagnoses and nursing actions in
terminological systems
1 Scope
This International Standard specifies the characteristics of two categorial structures, with the overall
aim of supporting interoperability in the exchange of meaningful information between information
systems in respect of nursing diagnoses and nursing actions. Categorial structures for nursing diagnoses
and nursing actions support interoperability by providing common frameworks with which to
a) analyse the features of different terminologies, including those of other healthcare disciplines, and
[3]–[8]
to establish the nature of the relationship between them,
[9]–[12]
b) develop terminologies for representing nursing diagnoses and nursing actions,
[3] [8] [13]
c) develop terminologies that are able to be related to each other, and
d) establish relationships between terminology models, information models and ontologies in the
[14]–[16]
nursing domain.
There is early evidence that the categorial structures can be used as a framework for analysing nursing
[17] [18] [19]
practice and for developing nursing content of electronic record systems.
This International Standard is applicable to the following user groups:
— developers of terminologies that include nursing diagnosis and nursing action concepts;
— developers of categorial structures and terminologies for other healthcare domains, to support
clarification of any relationship to or overlap with nursing concepts;
— developers of models for health information management systems such as electronic health records
and decision support systems, to describe the expected content of terminological value domains for
particular attributes and data elements in the information models;
— developers of information systems that require an explicit system of concepts for internal
organization, data warehouse management or middleware services;
— developers of software for natural language processing, to facilitate harmonization of their output
with coding systems.
It is not intended for use by clinical nurses without health informatics expertise. However, Annex C
provides an introduction to categorial structures to assist those without health informatics expertise
to contribute to its development, review, implementation and evaluation.
NOTE 1 Although the scope of testing and review of the first edition of this International Standard has been
limited to nursing, the two categorial structures have features in common with the more general framework for
clinical findings [ISO/TS 22789 and the domain-specific categorial structure for surgical procedures (ISO 1828)
[20] [2]
as well as with the WHO ICHI]. The standard may therefore inform development of other general and
domain-specific categorial structures in healthcare.
Topics considered outside the scope of this International Standard include
— complete categorial structures that would cover all the potential details that could appear in
expressions of nursing diagnoses and nursing actions,
— a detailed terminology of nursing diagnoses or nursing actions,
ISO 18104:2014(E)
— a “state model” for diagnoses or actions — for example, provisional diagnosis or absent diagnosis,
planned action or action not to be done — see Annex A,
— diagnoses made and actions undertaken by nurses working in other professional roles — see
Annex B — and
— knowledge relationships such as causal relationships between concepts — see Annex B.
NOTE 2 Throughout the main body of this International Standard, where terms such as nursing diagnosis
and nursing action are used, these refer to representation of these concepts in electronic systems, not to the
professional activity of making a diagnosis or performing an action.
2 Normative references
The following documents, in whole or in part, are normatively referenced in this document and are
indispensable for its application. For dated references, only the edition cited applies. For undated
references, the latest edition of the referenced document (including any amendments) applies.
ISO 17115, Health informatics — Vocabulary for terminological systems
ISO/TS 22789, Health informatics — Conceptual framework for patient findings and problems in
terminologies
EN 12381, Health informatics — Time standards for healthcare specific problems
EN 12264, Health informatics — Categorial structures for systems of concepts
3 Terms and definitions
For the purposes of this document, the following terms and definitions apply.
NOTE Where terms used in this document are not defined in this clause, they are considered to be generic to
the English language or not specific to this document. In cases where they are not defined in this document nor
generic to the English language, terms can be found using the Joint Initiative for Global Standards Harmonization
Health Informatics Document Registry and Glossary’s standards knowledge management tool (SKMT): www.
skmtglossary.org.
3.1 General
3.1.1
concept
unit of knowledge created by a unique combination of characteristics (3.1.4)
Note 1 to entry: A concept can have one or more names. It can be represented using one or more terms, pictures,
icons or sounds.
3.1.2
categorial structure
minimal set of domain constraints (3.1.5) for representing concept systems in a subject field
Note 1 to entry: Annex C provides further explanation.
3.1.3
category
division of sets of entities (3.1.6) regarded as having particular shared characteristics (3.1.4)
EXAMPLE Oral route, subcutaneous route and all other routes share characteristics particular to the
category route (3.4.3).
2 © ISO 2014 – All rights reserved

ISO 18104:2014(E)
Note 1 to entry: Categories may be more or less general. Where one category is subsumed by another, the isA
relation is asserted to obtain a hierarchy between the more specific or subsumed category and the more general
or subsuming category. For example, parenteral route is more general than intravenous route.
Note 2 to entry: Each entity (3.1.6) instantiates some category.
3.1.4
characteristic
abstraction of a property of an entity (3.1.6) or of a set of entities (3.1.6)
EXAMPLE Fever is a characteristic symptom of flu.
Note 1 to entry: Characteristics are used for describing concepts (3.1.1) and for differentiating categories (3.1.3).
3.1.5
domain constraint
rule prescribing the set of sanctioned characteristics (3.1.8) that are valid to specialize a concept
representation in a subject field
EXAMPLE Administration of drug possiblyhasRoute subcutaneous describes the fact that drugs can be
administered subcutaneously in the specific context that the terminology applies to.
Note 1 to entry: Different levels of sanctioning are possible, e.g. conceivable, sensible, usuallyInTheContextOf,
normal, necessary.
3.1.6
entity
any concrete or abstract thing of interest
EXAMPLE Aspirin, environment, parent, symptom, mobility
Note 1 to entry: This definition is similar to that for object in ISO 1087-1: anything perceivable or conceivable.
ISO 1087-1 notes that objects may be material (e.g. an engine, a sheet of paper, a diamond), immaterial (e.g.
conversion ratio, a project plan) or imagined (e.g. a unicorn). However, the term object is normally interpreted as
representing a material thing, therefore entity is preferred.
3.1.7
representation relation
semantic link
formal representation of a directed associative relation or partitive relation between two concepts
(3.1.1)
EXAMPLE hasFocus; actsOn.
Note 1 to entry: A representation relation (3.1.7) always has an inverse, i.e. another representation relation
with the opposite direction. The inverse may or may not be explicitly stated. For example, isFocusOf (inverse of
hasFocus); isTargetOf (inverse of actsOn).
3.1.8
sanctioned characteristic
formal representation of a type of characteristic (3.1.4)
EXAMPLE hasFocus symptom; hasSite altered structure.
3.1.9
terminological system
terminology
structured human and machine-readable representation of clinical concepts (3.1.1) required directly or
indirectly to describe health conditions and healthcare activities, and allow their subsequent retrieval
or analysis
Note 1 to entry: It also refers to the relationship of the terminology to the specifications for organizing,
communicating and interpreting such a set of concepts.
ISO 18104:2014(E)
3.2 Categories of healthcare entities for nursing diagnoses
3.2.1
clinical course
onset and/or duration
EXAMPLE Acute, chronic, sudden.
Note 1 to entry: See Annex A for discussion of clinical course
Note 2 to entry: Does not include time related expressions [see timing (3.2.9)].
3.2.2
clinical finding
any state observed directly or indirectly concerning a subject of care and their relationship with the
environment
Note 1 to entry: A single descriptor (e.g. anxiety, pain) can serve the role of both focus (3.2.4) and judgement
(3.2.5). Such clinical finding expressions are also valid for representation of nursing diagnoses.
3.2.3
degree
relative severity or intensity
EXAMPLE Mild, moderate, severe.
3.2.4
focus
area of attention
EXAMPLE Tissue integrity, body temperature, activity of daily living.
Note 1 to entry: Focus categories (3.1.3) that are valid for representation of a nursing diagnosis include, but are
not limited to property, process, structure, state, and behaviour.
Note 2 to entry: Focus may be qualified by site (3.2.7), for example, movement of leg, tissue integrity of left heel.
3.2.5
judgement
opinion or discernment related to a focus (3.2.4)
EXAMPLE Impaired, reduced, ineffective.
Note 1 to entry: Judgement categories (3.1.3) that are valid for representation of a nursing diagnosis include, but
are not limited to, alteration, adequacy, and effectiveness.
3.2.6
potential
inherent capacity for coming into being
Note 1 to entry: Descriptors for potential are limited to risk for and opportunity for and their synonyms.
3.2.7
site
anatomical structure
Note 1 to entry: Site categories (3.1.3) that are valid for expressions of nursing diagnoses are body component,
and altered structure (e.g. a wound).
4 © ISO 2014 – All rights reserved

ISO 18104:2014(E)
3.2.8
subject of information
type of entity (3.1.6) to which the nursing diagnosis refers
Note 1 to entry: Subject of information categories (3.1.3) valid for representation of a nursing diagnosis are
individual, group and physical environment.
Note 2 to entry: The implied subject of information is the subject of record (3.4.4) which is not generally expressed
in the terminological phrase. A term for subject of information should be used when necessary to disambiguate
the subject of information from the (implied) subject of the record, e.g. sibling distress vs. (patient) distress.
3.2.9
timing
occurrence or a point or period in time
EXAMPLE After meals, in childhood, morning.
Note 1 to entry: For representation of time-related concepts, refer to EN 12381.
3.3 List of authorized representation relations for nursing diagnoses
NOTE Inverse representation relation for hasX is isXFor unless otherwise noted.
3.3.1
hasClinicalCourse
representation relation (3.1.7) between the nursing diagnosis and qualifier clinical course (3.2.1)
EXAMPLE In the expression sudden reduction in body weight, the nursing diagnosis reduction in body weight
hasClinicalCourse sudden onset.
3.3.2
hasDegree
representation relation (3.1.7) between the nursing diagnosis and qualifier degree (3.2.3)
EXAMPLE Severe pain — hasFinding pain, hasDegree severe.
3.3.3
hasFinding
representation relation (3.1.7) between the nursing diagnosis and the clinical finding (3.2.2)
EXAMPLE Risk for infection — hasFinding infection, hasPotential risk for.
3.3.4
hasFocus
representation relation (3.1.7) between the nursing diagnosis and the focus (3.2.4)
EXAMPLE Excessive calorie intake — hasFocus calorie intake, hasJudgement excess.
3.3.5
hasJudgement
representation relation (3.1.7) between the nursing diagnosis and the judgement (3.2.5)
EXAMPLE Unable to perform activities of daily living — hasFocus performance of activities of daily living,
hasJudgement unable.
Note 1 to entry: Inverse representation of hasJudgement relation is isAppliedTo.
3.3.6
hasPotential
representation relation (3.1.7) between the nursing diagnosis and the descriptor of potential (3.2.6)
EXAMPLE Risk for pressure ulcer — hasFinding pressure ulcer, hasPotential risk for.
ISO 18104:2014(E)
3.3.7
hasSite
representation relation (3.1.7) referring to the anatomical structure that further specifies the position
of a focus (3.2.4)
EXAMPLE Reduced movement of arm — hasFocus movement, hasSite arm, hasJudgement reduced.
3.3.8
hasSubjectOfInformation
representation relation (3.1.7) between the nursing diagnosis and the category (3.1.3) of type of entity
(3.1.6) to which the nursing diagnosis refers
EXAMPLE Sibling distress — hasFinding distress, hasSubjectOfInformation sibling.
3.3.9
hasTiming
representation relation (3.1.7) between the nursing diagnosis and the qualifier timing (3.2.9)
EXAMPLE Postoperative nausea — hasFinding nausea, hasTiming postoperative.
3.4 Categories of healthcare entities for nursing actions
3.4.1
action
act performed by a healthcare actor with the intention of directly or indirectly improving or maintaining
the health of a person, group or population
[SOURCE: EN 13940-1:2006, modified.]
EXAMPLE Observation, injection, teaching, dressing, removal.
3.4.2
means
entity (3.1.6) or technique used in performing a nursing action (3.4.1)
Note 1 to entry: Categories (3.2.3) that are valid for expressions of means are resource, method, device, and
substance.
3.4.3
route
path through which something may pass
EXAMPLE Oral, subcutaneous, epidural.
3.4.4
subject of record
type of entity (3.1.6) about which the health record is made; normally the individual patient / client
Note 1 to entry: included for completeness as a sub type of target (3.4.5). A terminological expression might
not include an explicit descriptor for target when the target is the subject of record. For example, four hourly
observation, mobilization following surgery.
3.4.5
target
entity (3.1.6) that is affected by the action (3.4.1) (Example 1) or that provides the content of the action
(Example 2)
EXAMPLE 1 Wound, foreign body or insulin: as in débridement of wound, removal of foreign body, injection of
insulin.
EXAMPLE 2 Vital signs or diabetes self care: as in assessment of vital signs, diabetes self care education.
6 © ISO 2014 – All rights reserved

ISO 18104:2014(E)
Note 1 to entry: Categories (3.1.3) that are valid for expressions of target are body component, device, substance,
resource, process, physical environment, individual, group, clinical finding (3.2.2), and other categories that have
the role of focus (3.2.4) in the nursing diagnosis categorial structure. A nursing diagnosis can also be the target
of an action (3.4.1).
3.5 List of authorized representation relations for nursing actions
NOTE Inverse representation relation (3.1.7) for hasX is isXFor unless otherwise noted.
3.5.1
actsOn
representation relation (3.1.7) between the action (3.4.1) and the target(s) (3.4.5) which is affected by
the action or provides the content of the action
EXAMPLE 1 Removal of wound dressing — action removal actsOn wound dressing.
EXAMPLE 2 Parent education about weaning diet — action education actsOn weaning diet, actsOn parent.
Note 1 to entry: isTargetOf is the inverse representation relation (3.1.7) of actsOn.
3.5.2
hasMeans
representation relation (3.1.7) between the categories action (3.4.1) and means (3.4.2)
EXAMPLE Feeding via cup and spoon — action feeding hasMeans cup and spoon
3.5.3
hasRoute
representation relation (3.1.7) between the categories action (3.4.1) and route (3.4.3)
EXAMPLE Subcutaneous injection of insulin — action injection actsOn insulin, hasRoute subcutaneous route
3.5.4
hasSite
representation relation (3.1.7) between the categories target (3.4.5) and site (3.2.7)
EXAMPLE Removal of wound dressing — action removal actsOn dressing hasSite wound.
Note 1 to entry: In the categorial structure for nursing actions, site (3.2.7) is used to further specify the position
of a target (3.4.5). hasSite shall not be used in place of actsOn (3.5.1) when the target is an anatomical structure,
i.e. body component or altered structure. In the case, for example, of assessment of skin on heel:

CORRECT: action assessment actsOn skin of right heel;

INCORRECT: action assessment hasSite skin of right heel.
3.5.5
hasTiming
representation relation (3.1.7) between the categories action (3.4.1) and timing (3.2.9)
EXAMPLE Administration of anti-emetic drug before meals — action administration actsOn anti-emetic drug
hasTiming before meals.
4 Categorial structures — Conformance principles
Any categorial structure for representation of nursing diagnoses and nursing actions in a terminological
system shall conform with the requirements specified in EN 12264 and ISO 17115 and shall provide the
following information:
a) categories that organize the healthcare entities for representation of nursing diagnoses and actions
in the terminology and subdividing their representation in the domain;
ISO 18104:2014(E)
b) a list of the representation relations authorized by domain constraints;
c) the goal (purpose and scope) of the terminology for which the categorial structure is set;
d) a list of minimal domain constraints required by the goal of the categorial structure.
The categories that organize the healthcare entities and the representation relations for representation
of nursing diagnoses and nursing actions in terminological systems are defined in 3.2 to 3.5.
5 Categorial structure for representing nursing diagnoses
A nursing diagnosis shall be expressed either as a judgement on a focus, or as a single clinical finding
expression representing an altered state, altered process, altered structure, altered function or altered
behaviour observed about a subject of care. Examples of the first type of expression (i.e. a judgement on
a focus) include limited mobility, poor nutrition, and lack of knowledge. Examples of the second type of
expression (i.e. a clinical finding) include wound, nausea, pain, and depression.
For the first type of expression a descriptor for judgement and a descriptor for focus are mandatory.
Focus may be qualified by site.
Clinical findings shall be represented as specified in ISO/TS 22789.
A nursing diagnosis expression may have an associated potential which indicates that there is a risk for
or opportunity for a nursing diagnosis. Note that risk of is sometimes used instead of risk for. A risk is a
potential for a negative diagnosis; an opportunity (or chance) is a potential for a positive diagnosis. For
example, risk of depression, risk for pressure ulcer; opportunity for weight reduction, opportunity for
improved social interaction.
A nursing diagnosis expression may also be associated with a subject of information other than the
subject of the record, for example, caregiver stress, poor parenting skills.
A nursing diagnosis expression may be qualified by degree, clinical course and timing .
The categorial structure for nursing diagnoses is shown in Figure 1.
8 © ISO 2014 – All rights reserved

ISO 18104:2014(E)
Subject Of Information
0.1
Nursing Diagnosis
Degree [0.1]
Clinical Course [0.1]
Timing [0.1]
Potential
{either}
0.1
1 1
Clinical Finding Focus Judgement
{complete}
Risk For Chance For
0.1
Site
Figure 1 — Categorial structure for nursing diagnosis
6 Categorial structure for representing nursing actions
For the purposes of this International Standard, a nursing action is considered to be an intentional act
applied to one or more targets through an action. A nursing action expression shall have a descriptor for
action and at least one descriptor for target, except where the target is the subject of record and implied
in the expression.
Nursing actions may be qualified by means, route and timing. The category site may be used to further
specify the position of a target.
Actions are frequently represented in compositional expressions as verbs or verb phrases. Past tense
verbal forms and order/instruction forms shall not be used in expressions of nursing actions. For
example, observation shall be used rather than observed or observe (see Annex B).
Some nursing actions are expressed at an abstract level, for example: mouth care. Others are at a more
detailed level, for example, removal of sutures. This International Standard applies to nursing action
concepts at all levels of abstraction where these are included in terminological systems. The relationship
between the high level expression and the detail of what is actually done to, for or with the subject of care
is not in scope for this standard. Such relationships are specified in evidence based guidelines/resources
and are managed, if required, within the information model of healthcare systems (see Annex B).
A graphical representation of the categorial structure for nursing actions is shown in Figure 2.
ISO 18104:2014(E)
Nursing Action
Note
A Nursing Action MUST be
Route [0.1]
composed of one Action and at
Means [0.1]
least one target, except where
Timing [0.1]
the only target is the Subject Of
{either}
Record
11.*
Action Target Site
0.1
Subject Of Record
Figure 2 — Categorial structure for nursing actions
10 © ISO 2014 – All rights reserved

ISO 18104:2014(E)
Annex A
(informative)
Summary of changes to ISO 18104:2003
A.1 Summary of changes to nursing diagnosis categorial structure
A.1.1 Overview
ISO 18104:2003 A single expression for nursing diagnosis is an exception to the “judgement and
focus” model, for example, nausea, pain
Revision The single expression is an alternative rather than a special case.
Clinical finding expression is introduced. Mandatory requirement is for descrip-
tors of focus and judgement OR descriptor for clinical finding.
Categories for focus are revised to remove the “altered” examples that belong in
clinical findings.
Rationale “Special case” was confusing; whereas “single expression” fits with ISO/
TS 22789.
A.1.2 Judgement
ISO 18104:2003 Qualifiers of degree, acuity and timing are qualifiers of judgement
Revision Qualifiers of degree, clinical course and timing are qualifiers of diagnosis
Rationale These qualifiers can apply to clinical finding types of diagnoses, not just to
those that have a focus and judgement e.g. severe pain.
A.1.3 Dimension
ISO 18104:2003 Dimension is a quality possessed by an individual or group which provides a
perspective on, but is not limited to: process, structure, other semantic catego-
ries taking the role of focus, and nursing diagnosis
Revision Dimension and isPerspectiveOn removed
Rationale Ongoing confusion about use of this category and no evidence of use in termi-
nologies in the way it was intended i.e. to allow for post co-ordination of con-
cepts to reduce combinatorial explosion.
For example: combination of “ability to” with every self care activity; combina-
tion of “knowledge about” with every disorder. There is evidence that termi-
nology developers are using “ability” and “dependency” as measures or scores
rather than as they were in 18104:2003.
ISO 18104:2014(E)
A.1.4 Subject of information
ISO 18104:2003 Defined as an entity to which a diagnosis refers
Associated with focus in the diagrammatic model
Revision Defined as type of entity to which a nursing diagnosis refers
Notes amended to clarify use.
Rationale Confusion over when to use; Lack of reproducibility
Subject of information, subject of record and subject of care in EN 13940‑1
[21]
In EN 13940-1 , subject of care is defined as the person seeking to receive, receiving, or having received
healthcare. An informative annex discussed the situation where the subject of care was a group of
persons rather than an individual. This meaning of subject of care as an individual, group or population
is the one most commonly accepted in nursing. For example, a nursing diagnosis may be about a family
or a mother-child dyad.
Subject of care is not defined in this International Standard, as it is not included in the required categories
for expressions of nursing diagnosis and nursing action. However, two related categories are defined:
— Subject of information — type of entity to which a diagnosis refers e.g. “parent”, “caregiver”. The
default is the patient - this category is used when a nursing diagnosis about someone other than the
patient is recorded in the record of the patient.
— Subject of record — type of entity about which the health record is made; normally the individual
patient. In this International Standard, this category is included for completeness as a sub type of
target. A terminological expression might not include an explicit descriptor for target when the
target is the subject of record. For example: four hourly observation, mobilization following surgery.
Both of these may be the same as the subject of care as defined in EN 13940-1, however, they may also be
another “type of entity” such as a family member, a family or group.
A.1.5 Site (also used in the categorial structure for nursing actions)
ISO 18104:2003 Defined as A physical structure that further specifies the position of a focus or a
target. Example categories included body component, altered structure (e.g. a
wound), and device.
Revision Defined as anatomical structure. Device removed from examples
Rationale —  Site appeared to be interpreted as a geographical location type perhaps
instead of physical environment such as a school - not intended in the 2003 ver-
sion.
[20]
—  Alignment with ISO/TS 22789 and ISO 1828 .
—  The 2003 definition included how to use it, not permitted in ISO definitions.
12 © ISO 2014 – All rights reserved

ISO 18104:2014(E)
A.1.6 Potentiality
ISO 18104:2003 Potentiality is associated with judgement.
Descriptors of potentiality (possibility) include risk for, actual, possibility of, and
potential.
Revision Potential (preferred to potentiality — same meaning) is now associated with
nursing diagnosis. Defined to exclude possibility and actual. New definition:
inherent capacity for coming into being with descriptors limited to risk for and
opportunity for.
...