NursingIntervention-v3.0(2016EN)

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Attention!! This is not the most recent version of this information model. You can find the most recent version ''here''.

General information

Name: nl.zorg.NursingIntervention
Version: 3.0
HCIM Status:Final
Release: 2016
Release status: Published
Release date: 1-5-2016


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Metadata

DCM::CoderList Werkgroep RadB Verpleegkundige Gegevens
DCM::ContactInformation.Address *
DCM::ContactInformation.Name *
DCM::ContactInformation.Telecom *
DCM::ContentAuthorList Werkgroep RadB Verpleegkundige Gegevens
DCM::CreationDate 7-7-2014
DCM::DeprecatedDate
DCM::DescriptionLanguage nl
DCM::EndorsingAuthority.Address
DCM::EndorsingAuthority.Name PM
DCM::EndorsingAuthority.Telecom
DCM::Id 2.16.840.1.113883.2.4.3.11.60.40.3.14.2
DCM::KeywordList Interventie, verpleegkundige actie
DCM::LifecycleStatus Final
DCM::ModelerList Werkgroep RadB Verpleegkundige Gegevens
DCM::Name nl.zorg.VerpleegkundigeInterventie
DCM::PublicationDate 1-5-2016
DCM::PublicationStatus Published
DCM::ReviewerList Projectgroep RadB Verpleegkundige Gegevens & Kerngroep Registratie aan de Bron
DCM::RevisionDate 8-9-2015
DCM::Superseeds nl.nfu.VerpleegkundigeInterventie-v1.0
DCM::Version 3.0
HCIM::PublicationLanguage EN

Revision History

Concept

A nursing intervention is the care and/or treatment carried out by a nurse based on an expert opinion and clinical knowledge. It is part of the nursing process; interventions are determined as a result of indexed healthcare problems (nursing diagnoses) and based on treatment goals. The interventions are outlined in the nursing procedures.

Purpose

The nursing interventions are an essential part of the nursing process. A nursing intervention is recorded to document the nursing policy and to update other healthcare providers on the intervention. The documentation of nursing interventions offers the option to determine whether the interventions outlined in the treatment plan have been carried out. This way, we can facilitate optimal nursing and continuity of care.

Evidence Base

Various classifications can be used in an organization to support the nursing process (nursing diagnoses/ symptoms, interventions and healthcare results). The chosen classification system usually depends on the context of the care (and the accessibility of the classification). Commonly used systems include Omaha System, NANDA, NIC and NOC (also known as the NNN-classification) and ICF.

For more information, please refer to the ‘References’ section.

Information Model


#InterventionICNPCodelist#InterventionNICCodelist#InterventionOmahaCodelist#10022#10013#10025HealthProfessional-v3.0(2016EN)ConcernForTransfer-v3.0(2016EN)#10018#10020#10017HealthProfessional-v3.0(2016EN)#10026#10028#10029MedicalDevice-v3.0(2016EN)TreatmentObjective-v3.0(2016EN)


Type Id Concept Card. Definition DefinitionCode Reference
NL-CM:14.2.1 NursingIntervention Root concept of the NursingIntervention information model. This root concept contains all data elements of the NursingIntervention information model.
NL-CM:14.2.2 Intervention 1 A nursing intervention is a treatment carried out by a nurse based on an expert opinion and clinical knowledge for the benefit of the person requesting healthcare. The intervention is targeted towards a certain problem (diagnosis) and has a predetermined healthcare result. There are different classifications that describe interventions, including the NIC (National Intervention Classification) and the Omaha System. This information model uses coded interventions.
InterventionICNPCodelist
InterventionNICCodelist
InterventionOmahaCodelist
NL-CM:14.2.6 Indication::Problem 0..1 The nursing-related problem (indication) providing cause for the intervention.
ConcernForTransfer
NL-CM:14.2.14 TreatmentGoal 0..1 The description of the treatment goal that the intervention decision is based on.
TreatmentObjective
NL-CM:14.2.9 NursingProcedure 1..* Container of the NursingProcedure concept. This container contains all data elements of the NursingProcedure concept.
9632001 Nursing procedure
NL-CM:14.2.3 Interval 0..1 Interval indicates the time between planned procedures.

When entering an interval, the focus is on the time between the consecutive procedures, such as in the treatment of a wound, for example. The exact times are of lesser importance.

NL-CM:14.2.4 Frequency 0..1 The frequency describes how often and in which period certain procedures are carried out, e.g. 3x a day.
NL-CM:14.2.10 Activity 1 The description of nursing procedures carried out in the care for a patient. A nursing intervention consists of a set of patient-related nursing procedures.
NL-CM:14.2.11 ProcedureStartDateTime 0..1 The start date (and if possible start time) of the procedure. The concept offers the option to indicate the start of the period of a series of repeating procedures.
NL-CM:14.2.12 ProcedureEndDateTime 0..1 The end date (and if possible end time) of the procedure. The concept offers the option to indicate the end of the period of a series of repeating procedures.
NL-CM:14.2.13 MedicalAid::MedicalAid 0..* Description of the materials used for the nursing procedure, such as bandages.
MedicalDevice
NL-CM:14.2.7 CarriedOutBy::HealthcareProvider 0..1 The healthcare provider carrying out the nursing procedure.
HealthProfessional
NL-CM:14.2.8 RequestedBy::HealthcareProvider 0..* The healthcare provider who requested the nursing intervention. If desired, only the requester’s specialty can be entered.
HealthProfessional
NL-CM:14.2.5 Explanation 0..1 Explanation of the nursing intervention.
48767-8 Annotation comment

Columns Concept and DefinitionCode: hover over the values for more information
For explanation of the symbols, please see the legend page

Example Instances

Only available in Dutch

VerpleegkundigeInterventie
Interventie Pijnmanagement
Indicatie
ProbleemNaam Pijn
Behandeldoel
Streefwaarde
MetingNaam Pijnscore
UitslagWaarde <4
UitslagDatumTijd 10-09-2015
VerpleegkundigeActie
Activiteit Ondersteuning van de wond bij hoesten.
ActieStartDatumTijd 10-08-2015
ActieEindDatumTijd 15-08-2015
VerpleegkundigeActie
Activiteit Toedienen medicatie volgens voorschrift bij pijnscore > 4.
ActieStartDatumTijd 10-08-2015
Toelichting -

References

1. Richtlijn Verpleegkundige en verzorgende verslaglegging (V&VN, 2011) [Online] Beschikbaar op:http://www.diliguide.nl/document/4060/file/pdf/ [Geraadpleegd: 13 februari 2015]

2. Vreeke E, Klein Wolterink G. Classificatie- en terminologiestelsels voor verpleegkundige informatie. Nictiz & NFU (2014). [Geraadpleegd: 13 februari 2015]

3. The Omaha System [Online] Beschikbaar op:http://www.omahasystem.org/ [Geraadpleegd: 13 februari 2015]

4. Nursing Intervention Classification (NIC) [Online] Beschikbaar op:http://www.nursing.uiowa.edu/center-for-nursing-classification-and-clinical-effectiveness [Geraadpleegd: 13 februari 2015]

5. Nursing Outcome Classification (NOC) [Online] Beschikbaar op:http://www.nursing.uiowa.edu/center-for-nursing-classification-and-clinical-effectiveness [Geraadpleegd: 13 februari 2015]

6. North American Nursing Diagnosis Association (NANDA) [Online] Beschikbaar op:http://www.nanda.org/ [Geraadpleegd: 13 februari 2015]

7. International Classification for Nursing Practice (ICNP) [Online] Beschikbaar op:www.icn.ch[Geraadpleegd: 13 februari 2015]

8. International Classification of Functioning, Disability and Health (ICF) [Online] Beschikbaar op:http://www.rivm.nl/who-fic/icf.htm [Geraadpleegd: 13 februari 2015]

Valuesets

InterventionICNPCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.14.2.1 Binding:
Conceptname Codesystem name Codesystem OID
Alle waarden ICNP 2.16.840.1.113883.6.97

InterventionNICCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.14.2.2 Binding:
Conceptname Codesystem name Codesystem OID
Alle waarden NIC 2.16.840.1.113883.6.15

InterventionOmahaCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.14.2.3 Binding:
Conceptname Codesystem name Codesystem OID
Alle waarden Omaha 2.16.840.1.113883.6.98

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Technical specifications in HL7v3 CDA and HL7 FHIR

To exchange information based on health and care information models, additional, more technical specifications are required.
Not every environment can handle the same technical specifications. For this reason, there are several types of technical specifications:

  • HL7® version 3 CDA compatible specifications, available through the Nictiz ART-DECOR® environment
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About this information

The information in this wikipage is based on Release summer 2016
Conditions for use are located on the mainpage
This page is generated on 21/12/2018 16:29:14 with ZibExtraction v. 3.0.6929.24609


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