How nursing interventions classification fits in the patient information system Patient Core Data Set.
The patient information system Patient Core Data Set (PCDS) is a record of patient health/medical history. The PCDS has three domains: patient identification, service elements, and health elements. The health elements category has a "procedures/treatment rendered" section: "the code that identifies the principal procedure or service performed during the period covered by this bill, and the date the principal procedure or service was performed." This category has two subcategories titled medical procedures/treatment and nursing intervention. This subcategory of nursing intervention suggests the listing of Nursing Interventions Classification (NIC). Nursing Interventions are written on a conceptual level and require a series of discrete actions or activities. Each intervention has three parts: the intervention label, the intervention definition, and the required activities. These activities help define the intervention. Each intervention typically has 20 to 30 activities that are basic or task level. The NIC is a perfect fit for the PCDS. A description of NIC's development has been provided. It is evident that, for effective communication and documentation of nursing care, a standardized language is necessary.
Daly
J M
JM
College of Nursing, University of Iowa, USA.
D002965:Classification; D003625:Data Collection; D016347:Medical Records Systems, Computerized; D009732:Nursing Care / Q000145:classification*; D011159:Population Surveillance; D011795:Surveys and Questionnaires; D009626:Terminology as Topic; D014481:United States