Contributions of representing the elements of nursing practice in the ISO 18.104:2023 standard: a theoretical study

Author:

Cubas Marcia Regina1ORCID,Silva Rudval Souza da2ORCID,Primo Cândida Caniçali3ORCID,Brandão Marcos Antônio Gomes4ORCID,Félix Nuno Damácio de Carvalho5ORCID,Jensen Rodrigo6ORCID

Affiliation:

1. Pontifícia Universidade Católica do Paraná, Brazil

2. Universidade do Estado da Bahia, Brazil

3. Universidade Federal do Espírito Santo, Brazil

4. Universidade Federal do Rio de Janeiro, Brazil

5. Universidade Federal do Recôncavo da Bahia, Brazil

6. Universidade de São Paulo, Brazil

Abstract

ABSTRACT Objective: To reflect on the contributions of representing nursing practice elements in the ISO 18.104:2023 standard. Method: This is a theoretical study with standard analysis. Categorical structures were described to represent nursing practice in terminological systems and contributions identified in the parts of the version were analyzed. Results: There is innovation in the inclusion of nurse sensitive outcomes, nursing action, nursing diagnosis explanation as an indicator of nursing service demand and complexity of care, representation of concepts through mental maps and suggestion of use of restriction models for nursing actions. It describes that the Nursing Process is constituted by nursing diagnosis, nursing action and nurse sensitive outcomes. Final considerations: Indicating a nursing diagnosis as an indicator will bring benefits for knowledge production and decision-making. Although care outcomes are not exclusive responses to nursing action, the modifiable attributes of a nursing diagnosis generate knowledge about clinical practice, nursing action effectiveness and subjects of care’ health state. There is coherence in understanding the Nursing Process concept evolution.

Publisher

FapUNIFESP (SciELO)

Reference12 articles.

1. ISO 18104: Health Informatics integration of a reference terminology model for nursing,2003

2. NBR-ISO 18104: Informática em saúde — Estruturas de categorias para a representação de diagnósticos de enfermagem e ações de enfermagem em sistemas de terminologia,2014

3. ISO 18104: Health informatics — Categorial structures for representation of nursing practice in terminological systems,2023

4. Quality criteria, instruments, and requirements for nursing documentation: a systematic review of systematic reviews;De Groot K;J Adv Nurs,2019

5. The use of SNOMED CT, 2013-2020: a literature review;Chang E;J Am Med Inform Assoc,2021

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