A review of major nursing vocabularies and the extent to which they have the characteristics required for implementation in computer-based systems.
Building on the work of previous authors, the Computer-based Patient Record Institute (CPRI) Work Group on Codes and Structures has described features of a classification scheme for implementation within a computer-based patient record. The authors of the current study reviewed the evaluation literature related to six major nursing vocabularies (the North American Nursing Diagnosis Association Taxonomy 1, the Nursing Interventions Classification, the Nursing Outcomes Classification, the Home Health Care Classification, the Omaha System, and the International Classification for Nursing Practice) to determine the extent to which the vocabularies include the CPRI features. None of the vocabularies met all criteria. The Omaha System, Home Health Care Classification, and International Classification for Nursing Practice each included five features. Criteria not fully met by any systems were clear and non-redundant representation of concepts, administrative cross-references, syntax and grammar, synonyms, uncertainty, context-free identifiers, and language independence.
Department of Community Health Systems, School of Nursing, University of California-San Francisco, USA. nursing%sue_henry@ccmail.ucsf.edu
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D005069:Evaluation Studies as Topic; D016347:Medical Records Systems, Computerized; D009729:Nursing / Q000145:classification*; D009626:Terminology as Topic; D018875:Vocabulary, Controlled