by Rita D. Zielstorff, MS, RN, FAAN

Article originally published Sept. 30, 1998

The reasons for developing a vocabulary or nomenclature usually dictate its characteristics (Ingernerf, 1995). For example, if a nomenclature is developed primarily for classifying nursing intensity, its terms will describe patient characteristics that impact resources needed for care. If a nomenclature is developed primarily for billing, then its terms will describe actions or procedures that can be billed to a third party. In nursing, as in most other health disciplines, there are no nomenclatures that have been developed primarily for use in automated clinical information systems. Therefore, designers of information systems that rely on capturing and using structured clinical information have had to make do with nomenclatures that were designed for other purposes. A great deal of work has been done in the past few years to examine existing nomenclatures for their suitability for automated clinical systems, and most have been found significantly lacking (Campbell, 1997; Henry, 1998). In this paper, we will examine how data are used in automated clinical systems, and review the resulting requirements of a "good" nomenclature from the perspective of a system designer.

It is important to state at the outset that a great deal of excellent work has been done with respect to nursing nomenclatures in the past few decades. Among the earliest is the work done at the Omaha Visiting Nurses Association to classify the problems that nurses define in the home health setting, along with the expected outcomes, the interventions that nurses use, and the actual patient outcomes. This set of terms and the recommended methods of using them is known as the Omaha System (Martin & Scheet, 1992). Among the best known nomenclatures is the North American Nursing Diagnosis Association (NANDA) Approved List of diagnostic labels (North American Nursing Diagnosis Association, 1994). More recent work includes the Nursing Interventions Classification (NIC), developed at the University of Iowa (McCloskey & Bulechek, 1996), the Home Health Care Classification (HHCC) developed at Georgetown University (Saba, 1992), and the Nursing Outcomes Classification (NOC), also developed at the University of Iowa (Johnson & Maas, 1997). At the University of Virginia, Ozbolt and colleagues culled hundreds of terms from patient records to develop the Patient Care Data Set (PCDS) (Ozbolt, Fruchtnicht & Hayden, 1994; Ozbolt, 1996), which codifies patient problems and actions delivered by all caregivers during a patient's hospital stay.

All of the aforementioned nomenclatures have been recognized by the American Nurses Association as nomenclatures that should be included in a Unified Nursing Language System (Lang, 1995). All have been or are in the process of being added to the Unified Medical Language System developed and supported by the National Library of Medicine (Lindberg, Humphreys & McCray, 1993).

Today's health care environment demands that automated patient record systems deliver the following functions:

1. Provide the legal record of care
2. Support clinical decision making
3. Capture costs for billing, costing and/or accounting purposes
4. Accumulate a structured, retrievable data base for
   a. administrative queries
   b. quality assurance
   c. research
5. Support data exchange with internal and external systems

All of these functions depend on data. Each function places requirements on the nomenclature that is used to capture and store that data. As we will see, sometimes these requirements conflict with one another, which further confounds the effort to develop a single, comprehensive nomenclature for use in automated systems. Each function will be discussed in turn.