EN ISO 18104:2023 PDF

Overview

EN ISO 18104:2023 - Health informatics - Categorial structures for representation of nursing practice in terminological systems defines a common framework for representing nursing diagnoses, nursing actions, and nurse sensitive outcomes in computer-processable terminologies. Published as the third edition, this ISO/CEN standard updates and supersedes the 2014 edition to strengthen semantic interoperability across electronic health records (EHRs), terminological systems and ontologies used in nursing and multi‑disciplinary care.

Key topics and technical requirements

• Categorial structures: Specifies categories and sub‑categories for modelling nursing practice (diagnoses, actions, outcomes) to enable consistent representation and exchange of nursing data.
• Semantic links and constraints: Defines representation relations and domain constraints that govern how concepts (e.g., Assessment as an Observation) interrelate.
• Interoperability support: Focus on enabling mapping and relationships between terminologies (pre- and post-coordinated expressions), information models (including archetypes), and ontologies.
• Expanded content for 2023 edition: Adds nurse sensitive outcomes and sub‑categories (including confounding variables), goal/expected outcomes, Outcome Causation distinctions, and recognition of collaborative nurse–subject-of-care roles.
• Reference alignments: Includes references to ISO 13606‑2, openEHR RIM and the incorporation of ICNP into SNOMED CT® as part of supporting practical terminological integration.
• Requirements for implementers: Guidance for analysing existing terminologies, developing new nursing terminologies, and relating multiple terminology models to each other and to clinical information models.

Practical applications

• Develop and evaluate nursing terminologies and concept models for use in EHRs and clinical decision support.
• Map and harmonize nursing content between systems (e.g., ICNP, SNOMED CT) to achieve semantic interoperability.
• Design archetypes or information models that embed nursing diagnoses, actions and outcomes for documentation, quality measurement and research.
• Support analytics for nursing outcomes, resource management, reimbursement, and to make the nursing contribution visible in care delivery.
• Use as a framework to assess and compare terminologies, including pre‑ and post‑coordinated term sets.

Who should use this standard

• Health informaticians and terminology developers
• EHR and clinical documentation system vendors
• Nursing informatics specialists, clinical leads and researchers
• Standards bodies, policy makers and healthcare data governance teams

Related standards and keywords

Related references include ISO 13606‑2, openEHR RIM, ICNP, SNOMED CT and other health informatics standards. Keywords: EN ISO 18104:2023, health informatics, nursing terminologies, nursing diagnoses, nursing actions, nurse sensitive outcomes, interoperability, electronic health records, semantic interoperability.