A comparison between the ICNP and the ICF for expressing nursing content in the electronic health record.

BACKGROUND

The use of standardised terminologies for electronic health records (EHRs) is important and a sufficient coverage of all aspects of health care is increasingly being developed worldwide. The International Classification of Functioning, Disabilities and Health (ICF) is suggested as a unifying terminology suitable in a multi-professional EHR, but the level of representation of nursing content is unclear.

OBJECTIVES

The aim was to describe lexical and semantic accordance in relation to comprehensiveness and granularity of concepts between the International Classification of Nursing Practise (ICNP) and the ICF.

METHODS

806 pre-coordinated concepts for diagnoses and outcomes in the ICNP terminology were manually mapped to 1516 concepts on level 4-6 in the ICF.

RESULTS

Several dimensions of nursing diagnoses and outcomes in the ICNP were missing in the ICF. 60% of the concepts for diagnosis and outcome in the ICNP could not be stated using the ICF while another 31% could only be matched either as a subordinate or as a superordinate concept.

CONCLUSIONS

The lexical and semantic accordance in relation to comprehensiveness and granularity between concepts in the ICNP and ICF was rather low. A large proportion of concepts for diagnoses and outcomes in the ICNP could not be satisfactorily stated using the ICF. Standardised terminologies rooted in a nursing tradition (e.g., the ICNP) is needed for communication and documentation in health care to represent the patient's health situation as well as professional diagnostic decisions and evaluations in nursing.