Representing Nursing Interventions

Type	Standard / Implementation Specification	Standards Process Maturity	Implementation Maturity	Adoption Level	Federally required	Cost	Test Tool Availability
Standard	SNOMED CT® U.S. Edition	Final	Production	Feedback Requested	No	Free	N/A

Limitations, Dependencies, and Preconditions for Consideration	Applicable Value Set(s) and Starter Set(s)
According to the Journal of Nursing Education nursing interventions can be defined as "any task that a nurse does to or for the patient" or "something that directly leads to a patient outcome." Coded interventions may be linked as related/dependent concepts to observations and assessments, as appropriate. The Procedure axis of SNOMED CT U.S. Edition is the terminology used for Nursing Interventions.	A resource available is a map set from ICNP to SNOMED CT U.S. Edition.

Limitations, Dependencies, and Preconditions for Consideration

Applicable Value Set(s) and Starter Set(s)

According to the Journal of Nursing Education nursing interventions can be defined as "any task that a nurse does to or for the patient" or "something that directly leads to a patient outcome."
Coded interventions may be linked as related/dependent concepts to observations and assessments, as appropriate.
The Procedure axis of SNOMED CT U.S. Edition is the terminology used for Nursing Interventions.

A resource available is a map set from ICNP to SNOMED CT U.S. Edition.

Comment

Submitted by gldickinson on 2020-10-23

Preserving Clinical Context

General Comments:

USCDI specifies lots of clinical data classes and data elements

Resolving to myriad de-coupled fragments
With vanishingly little focus on:
- Clinical context and vital inter-relationships, e.g., between problems, diagnoses, complaints, symptoms, encounters, history and physical findings, allergies, medications, vaccinations, assessments, goals/objectives, clinical decisions, orders, results, diagnostic procedures, interventions, observations, treatments/therapies, referrals, consults, outcomes, protocols, care plans and status...
- Elements and context + purpose of capture: e.g., blood pressure, its measurement (systolic, diastolic), its unit of measure (mm/Hg), its reason for capture, its context of capture (sampling site, sampling method, patient position, at rest/during/post exercise...

It is crucial to consider, determine and resolve how clinical content and context are bound together and preserved in USCDI. The ultimate end user (often a clinician) must be able to readily discern context and inter-relationships – otherwise USCDI places an undue (and often unresolvable) burden on this user. Only the source EHR/HIT system can structure clinical content and context properly. Once data is stuffed into the USCDI framework and related exchange artifact (e.g., FHIR resources) this opportunity is forever lost.

Submitted by cmcdonald on 2018-10-01

Should clarify what is meant…

Should clarify what is meant by a nursing intervention and provide a definition and examples. If a request for vital signs is a nursing intervention then it will be hard to know when the request is fulfilled. if the code doesn't match it will be hard to manage the process from request to fulfillment

Submitted by dvreeman on 2017-11-20

We are delighted to see the…

We are delighted to see the addition of Nursing content in the 2017 ISA and concur with all of the recommendations for use of LOINC and SNOMED CT.