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Efforts to develop an International Classification for Nursing Practice (ICNP) were initiated nearly a decade ago. To update nurses on progress, below is a critical review of the ICNP using the Computer-based Patient Record Institute (CPRI) Features Framework and a discussion of its relevance to current US efforts: 1) the activities of the American Nurses' Association (ANA) Steering Committee on Databases To Support Clinical Nursing Practice; 2) implementation of formal approaches for representing nursing concepts and 3) Health Level 7 standards.

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.

Although several coding systems for standardizing the clinical language of nursing practice have been developed and tested, no studies have been found that examine the usefulness of such a system for psychiatric home care, a rapidly emerging area of nursing practice. This study examined the usefulness of the Georgetown Home Health Care Classification system for the coding of patient problems and nursing interventions in the psychiatric home care setting. Although most problems and interventions could be classified with codes from the Georgetown system, some new codes were needed to prevent loss of potentially significant psychiatric data.

Our premise is that from the perspective of maximum flexibility of data usage by computer-based record (CPR) systems, existing nursing classification systems are necessary, but not sufficient, for representing important aspects of "what nurses do." In particular, we have focused our attention on those classification systems that represent nurses' clinical activities through the abstraction of activities into categories of nursing interventions. In this theoretical paper, we argue that taxonomic, combinatorial vocabularies capable of coding atomic-level nursing activities are required to effectively capture in a reproducible and reversible manner the clinical decisions and actions of nurses, and that, without such vocabularies and associated grammars, potentially important clinical process data is lost during the encoding process. Existing nursing intervention classification systems do not fulfill these criteria. As background to our argument, we first present an overview of the content, methods, and evaluation criteria used in previous studies whose focus has been to evaluate the effectiveness of existing coding and classification systems. Next, using the Ingenerf typology of taxonomic vocabularies, we categorize the formal type and structure of three existing nursing intervention classification system--Nursing Interventions Classification, Omaha System, and Home Health Care Classification. Third, we use records from home care patients to show examples of lossy data transformation, the loss of potentially significant atomic data, resulting from encoding using each of the three systems. Last, we provide an example of the application of a formal representation methodology (conceptual graphs) which we believe could be used as a model to build the required combinatorial, taxonomic vocabulary for representing nursing interventions.

Developers of healthcare information systems are challenged by the difficulty of meeting the simultaneous goals of 1) capturing and electronically representing the broad array of data related to healthcare with sufficient expressibility to provide adequate documentation of the patient encounter, and 2) utilizing standardized coding and classification systems to facilitate linkages among computer-based systems. The evaluation studies to date have primarily focused on matching actual clinical data with terms in the recognized classification systems. These studies have provided evidence that the classification systems are relatively domain complete for categorizing patient problems and nursing interventions. Although several of the published criteria for evaluation relate to structure, it is noteworthy that this has not yet been a major focus of study in nursing. There are several areas of critical need that must be addressed. First, additional work is needed to develop and refine a standardized set of atomic-level terms relevant to nursing, including those for assessments, problems, and activities. Second, knowledge representations must be developed to support the building of complex concepts from atomic-level data.

Purpose: To compare the frequency with which nursing activity terms could be categorized using Nursing Interventions Classification (NIC) and Current Procedural Terminology (CPT) codes., Design: Descriptive. The sample was 201 patients with AIDS hospitalized 1989-1992 for pneumocystis carinii pneumonia in three US medical centers., Methods: Nursing activity terms (n = 21,366) were collected from patient interviews, nurse interviews, intershift reports, and patient records, then were categorized using NIC and CPT codes., Results: Nursing activity terms were categorized into 80 NIC interventions across 22 classes and into 15 CPT codes. All terms in the data set were classifiable using the NIC system and the majority (60%) of the terms were classified into 14 NIC intervention categories; 6% of the terms were classifiable by CPT codes. The most frequently used CPT code was "pulse oximetry." Significantly (p < .0001) greater numbers of nursing activity terms could be categorized in the NIC system compared to the CPT system., Conclusions: Findings provide evidence that NIC is superior to CPT for categorizing nursing activities in this study's population. The findings support the importance of discipline-specific classifications for categorization of health care interventions. Nursing-specific intervention classification systems such as NIC, the Omaha System, and the Home Health Care Classification are essential to defining the contribution of nursing to both quality and cost outcomes.

A variety of strategies for knowledge representation have been applied to the texts from a number of medical domains. Many of the techniques rely on the well-defined ways in which medical terms are used within a given domain, a phenomenon referred to as 'sublanguage.' Because much of nursing documentation involves the use of 'everyday' language, the viable application of sublanguage-based approaches to knowledge representation of nursing documentation is not a forgone conclusion. We propose an approach utilizing semantic markup of nursing notes as a strategy for determining whether the documentation of 'what nurses do' is a sublanguage Results of an initial feasibility study utilizing the approach are presented.

The American Nurses Association Steering Committee on Databases to Support Nursing Practice has recognized three standardized nursing intervention classification systems. Because each of these classifications systems focuses on encoding informational abstractions of nursing actions, rather than providing a controlled vocabulary and compositional grammar from which informational concepts and abstractions can be constructed, the systems are necessary, but not sufficient, for representing what nurses do. In particular, computer based patient record systems focused on process understanding and process improvement will require atomic-level representations of nursing actions suitable for transformation into a variety of information abstractions, including, but not limited to, the abstractions contained in the three existing classification systems.

1. RESEARCH OBJECTIVES AND METHODS. Because of a need for a standard classification and coding system to encode data for HIV infected patients in the AIDS Program clinic at San Francisco General Hospital, we have begun a subset of clinical terms commonly used in the care of patients with HIV disease, and we have sought to represent these terms using terminology from the SNOMED International classification system. We selected a sample of key findings for AIDS primary care for the AIDS Registry database. The areas of chest x-ray findings, psychological problems, and patient symptoms were chosen because they were representative of a number of SNOMED International axes, including diagnoses, morphology, topography, and function. They also included modifiers representing the concepts of laterality, time, severity, and certainty. 2. RESULTS. As shown by the sample terms in the table below, the findings suggest that SNOMED is a good starting point for a standard classification and coding system to support the clinical care of patients with HIV disease. The next phase of the research will focus on the evaluation of the adequacy and acceptability of the SNOMED representation to clinicians in the AIDS clinic.