ISO 18104:2023 健康情報学 | ページ 6

3.1.1

コンセプト

特性を組み合わせることによって構築される知識のサブセット (3.1.4)

注記 1: 概念には1 つ以上の名前を付けることができます。それは、1 つ以上の用語、画像、アイコン、または音声を使用して表すことができます。

3.1.2

カテゴリ構造

正確な 目標 (3.2.3) を達成するために、正確なドメインで概念システムを表現するための最小限の ドメイン制約セット (3.1.5 )

注記 1: 付録 B に詳しい説明が記載されています。

[出典: ISO 17115:2020, 3.1.1 修正 - 「対象分野」を「正確な目標を達成するための正確な領域」に置き換える。

3.1.3

カテゴリー

特定の共通の 特性（3.1.4） を持つとみなされる エンティティの集合（3.1.6 ）の分割

注記 1:カテゴリは多かれ少なかれ一般的なものであり、個々のケア対象または介護者のグループが含まれます。あるカテゴリが別のカテゴリに包含される場合、isA 関係がアサートされて、より具体的なまたは包含されるカテゴリ (サブカテゴリ) と、より一般的なまたは包含されるカテゴリの間の階層が取得されます。

注記 2:各 エンティティ (3.1.6) は、 いくつかのカテゴリをインスタンス化します。

3.1.4

特性

プロパティの抽象化

注記 1:特性は、 概念の説明 (3.1.1) および カテゴリーの区別 (3.1.3) に使用されます。

3.1.5

ドメイン制約

対象分野の概念表現を特殊化するために有効な一連の 認可された特性 (3.1.8) を規定する規則

注記 1:さまざまなレベルの制裁が可能である。たとえば、考えられる、慎重な、通常は状況に応じて、通常の、必要な。

3.1.6

エンティティ.エンティティ

概念 (3.1.1) 関心のある具体的または抽象的なものの図式的なグループとして表現される

3.1.7

代表関係

セマンティックリンク

2 つの 概念間の有向結合関係または部分関係の形式的表現 (3.1.1)

注記 1: 表現関係 (3.1.7) は 常に逆方向、つまり反対方向の別の表現関係を持ちます。逆は明示的に述べられる場合もあれば、述べられない場合もあります。たとえば、isFocusOf (hasFocus の逆); isTargetOf (actsOn の逆)

3.1.8

認可された特性

特性のタイプの正式な表現 (3.1.4)

3.1.9

用語体系

健康状態や医療活動を説明し、その後の検索や分析を可能にするために直接的または間接的に必要とされる臨床 概念 (3.1.1) を人間および機械が読み取り可能な構造化表現。

3.1.10

属性

データベース内のフィールドまたはタグのプロパティを決定する情報の一部

注記 1:属性は用語によって表される場合があります。

3.1.11

修飾子

これが属するカテゴリの意味を制限または変更する

3.1.12

情報モデル

1 つ以上のヘルスケアまたは臨床の概念とそのコンテキストを標準化された再利用可能な方法で概念的かつ論理的なモデルで表現し、データ要素の個別のセットとしてヘルスケア情報、それらの特性と関係、および適切な用語バインディングを指定するモデル。

[出典:ISO 13972:2022, 3.1.13, 修正済み]

3.1.13

看護師

ある時点での健康、行動、社会的、身体的状況に応じて、ケア対象、介護者、大切な人たちに自律的で協力的かつ総合的なヘルスケアを提供する特別な訓練を受けた個人

注記 1: ケアの対象には、診療範囲に応じて、あらゆる医療現場の個人またはあらゆる年齢、家族、グループおよび地域社会、病気または健康な状態が含まれる場合があります。

注記 2: 看護には、助産師、産科ケア、および看護の文脈で提供されるその他の専門サービスが含まれます。

グレード 3 からエントリーまで:看護師は、受けた治療を含む医療サービスに応じて、ケア対象者、介護者、および大切な人たちにサポートと慰めを提供します。

3.1.14

大切な人

ケア対象者と密接な関係にある友人、パートナー、家族

3.2.1

observation

assessment of the status of a subject of care (3.2.2)

Note 1 to entry: It is a sub-category of nursing action (3.4.1) .

Note 2 to entry: Assessment includes one or a combination of a measurement, evaluation or judgment that relates to a variable pertaining to the status of a subject of care (3.2.2) .

Note 3 to entry: Observation sub-category that are valid for representation of a type of assessment or activity, including a nursing diagnosis (3.2.7) , include, but are not limited to measure (3.3.12) , status (3.3.13) , site (3.3.3) , information from subject of care/carer (3.3.14) and from other care providers.

3.2.2

subject of care

one or more persons scheduled to receive, receiving, or having received a health service

Note 1 to entry: Subject of care category (3.1.3) valid for representation of a type of assessment or activity, including nursing diagnosis (3.2.7) , are subjected to associated individuals, e.g. personal carer, or subject of care preferences and event objectives.

Note 2 to entry: Includes individuals, family, community or population groups.

3.2.3

goal

specified outcome or condition to be achieved in the process of subject of care (3.2.2) care

Note 1 to entry: Its sub-categories are focus of goal (3.3.7) and target timeframe (3.3.6) .

3.2.4

event objective

determines data differentiation from other data required for a different user or use case

Note 1 to entry: Its sub-category is the use case type (3.3.8) .

3.2.5

associated individual

person of significance to the subject of care (3.2.2)

Note 1 to entry: Its attribute (3.1.10) is the relationship to the subject of care (3.2.2) .

3.2.6

choice

subject of care (3.2.2) preferred treatment or care option

3.2.7

nursing diagnosis

result of a nursing assessment following a nursing action (3.4.1)

Note 1 to entry: This result is used to inform nursing service delivery method (3.5.1) requirements at the point of care or nurse sensitive outcome (3.6.1) at a subsequent point in time.

Note 2 to entry: A nursing diagnosis is a label assigned to a judgement based on an assessment finding, event, situation or other health issue to indicate that it is considered to be noteworthy by the nurse and where possible, the subject of care.

3.3.1

clinical course

characteristic (3.1.4) of the evolution of the health state over time in conjunction with medical treatment

Note 1 to entry: See Annex A for discussion of clinical course.

Note 2 to entry: Does not include time related expressions [see timing (3.5.6) ].

Note 3 to entry: Refers to the individual’s response to medical treatment as observed at any point in time.

3.3.2

severity

degree of seriousness of clinical finding (3.7.1) or intensity

Note 1 to entry: A number of scoring systems are in use to take into account factors that influence type and timing (3.5.6) of nursing action (3.4.1) to be taken and their outcomes. Their use enables comparisons to be made between subject of care (3.2.2) .

3.3.3

site

anatomical structure

Note 1 to entry: Site category (3.1.3) that are valid for expressions of nursing diagnoses (3.2.7) are body component, and altered structure (e.g. a wound).

3.3.4

related event

occurrence that can be considered as a symptom or a cause when correlated with a nursing diagnosis (3.2.7)

Note 1 to entry: Events include an adversity such as post-operative infection, a fall, drug administration error or another incident.

3.3.5

identifier

unique object, token, code or set of variables that differentiates between individual subjects of care (3.2.2)

3.3.6

target timeframe

date/time of desired goal attainment of a change in, or termination of a nursing diagnosis (3.2.7) at a subsequent point in time

3.3.7

focus of goal

area of attention

Note 1 to entry: Focus may be qualified by site (3.3.3) , and measure (3.3.12) for example, movement of leg, tissue integrity of left heel.

3.3.8

use case type

usage scenario used in system analysis to identify, clarify and organize data retrieval to suit a specific purpose

Note 1 to entry: Measure the cause of a type of nurse sensitive outcome (3.6.1) to generate new knowledge for one of many purposes to be used to improve an operational activity.

3.3.9

relationship to subject of care

way in which or purpose of another individual to be connected to the subject of care (3.2.2)

Note 1 to entry: This may be one or many of the following formal or informal connections, social, legal, financial, practical, family to share with or meet the needs of a subject of care.

3.3.10

allergy

damaging immune response by the body to one or many substances

Note 1 to entry: A known likely physiological response to a medication or material such latex or wool or food substance.

Note 2 to entry: Shall be differentiated from diet intolerance (3.3.11) .

3.3.11

diet intolerance

difficulty digesting certain foods known to result in one or more damaging immune responses by the body to one or more substances

3.3.12

measure

quantified size, amount, value or degree of (something) observed by using an instrument or device marked in standard units

Note 1 to entry: This includes qualitative observation (3.2.1) converted by using a standard scale.

Note 2 to entry: May be documented as an evaluative statement.

3.3.13

status

situation at a particular point in time during a process

Note 1 to entry: Observation (3.2.1) that form part of an assessment process, including potential of risk.

3.3.14

information from subject of care/carer

contributions provided by the subject of care and/or significant other

3.4.1

NursingAction

activity intended directly or indirectly to improve or maintain a health state

Note 1 to entry: Includes assessments made to specify a Nursing Diagnosis as represented by observatory activities.

Note 2 to entry: Includes assessment, evaluation and planning actions as well as those that include the actions of “caring for”, “administration”, “feeding”, “performance”.

Note 3 to entry: A nursing diagnosis is a label for the result of an action ( observation (3.2.1) performed by or under the direction of a nurse, with the intention of directly or indirectly improving or maintaining the health and well being of a person, group or population, the precise scope of nursing actions being delineated in each jurisdiction.

3.4.2

target

entity (3.1.6) that is affected by the nursing action (3.4.1) or that provides the content of the nursing action

Note 1 to entry: Category (3.1.3) that are valid for expressions of target (3.4.2) are body component, device, substance, resource, process, physical environment, individual, group, clinical finding (3.7.1) , and other categories that have the role of focus in the nursing diagnosis (3.2.7) categorial structure. A nursing diagnosis can also be the target of a nursing action (3.4.1) .

3.5.1

service delivery method

ways nursing values and human resources are used to care for and treat subject of care (3.2.2)

3.5.2

action type

observatory or behavioural or physical or social or educational activity undertaken by one or more actor

Note 1 to entry: Nursing action (3.4.1) are also known as nursing interventions which may be specified within a nursing terminology.

3.5.3

action frequency

number of repeating occurrences of a nursing action (3.4.1)

3.5.4

technique

way of undertaking a particular task

3.5.5

tool used

piece of equipment or device used to support a nursing action (3.4.1)

3.5.6

timing

choice, request, order or control of when an action must be and/or is undertaken

3.5.7

location

place, position, point, spot or area targeted for a nursing action (3.4.1)

Note 1 to entry: Place refers to physical location.

3.5.8

record

semantically indivisible clinical statement which can be structurally large or small, but which loses meaning if broken up

Note 1 to entry: An indivisible clinical statement represents a piece of evidence recorded in the record.

3.6.1

nurse sensitive outcome

state observed and/or measured directly or indirectly concerning a subject of care (3.2.2) and their relationship with the environment at a point in time and documented to suit a use case

Note 1 to entry: For instance, to assess the performance of a method or service delivery process associated with a nursing action (3.4.1) or an organization or subject of care (3.2.2) .

Note 2 to entry: A single descriptor (e.g. anxiety, pain) can serve the role of the sub-category, focus of goal (3.3.7) target timeframe (3.3.6) and clinical finding (3.7.1) . Such clinical finding expressions are also valid for the representation of a type of assessment, including a nursing diagnosis (3.2.7) .

Note 3 to entry: Measures include the application of a standard or indicators making use of one or more dimensions of performance, such as timeliness or availability.

Note 4 to entry: Result of observation (3.2.1) made pertaining to a set of processes associated with the delivery of health and nursing services, as determined by nursing action (3.4.1) taken and influenced by one or more of the outcome causation (3.6.2) sub-categories

Note 5 to entry: The health outcome status referred to here is within the context of admission health status, one or many causations, social determinants of health and other environmental factors associated with the subject of care (3.2.2) relevant to a specified time period.

Note 6 to entry: The correct manner is determined by the current state of knowledge, to achieve the desired or projected outcome for the subject of care (3.2.2) .

Note 7 to entry: A nurse sensitive outcome (3.6.1) is a label assigned to the status of a nursing diagnosis (3.2.7) at points of time after one or more nursing action (3.4.1) which may be referred to as interventions by a terminological system in use.

Note 8 to entry: A nurse sensitive outcome (3.6.1) identifies the extent of change in a finding or nursing diagnosis or the achievement of goals/expected outcomes or the value of nursing services delivered, including modifications made due to the constraints that were outside the control of the nursing service provided.

3.6.2

outcome causation

way by which one of its sub-categories were demonstrated to have contributed to (causality) necessary modifications of one of the action category’s attributes resulting in the nurse sensitive outcome (3.6.1)

3.7.1

clinical finding

clinical assessment, including a nursing diagnosis (3.2.7) , resulting from assessment observation (3.2.1) made

Note 1 to entry: This is data that includes measured or observed results relative to provider and/or recipient(s) desired or projected outcome goal (3.2.3) , actual outcome state at a point in time.

Note 2 to entry: Includes a clinical (evaluative statement) reported outcome: Assessment of subject of care (3.2.2) outcomes made by a clinician. These outcomes are usually based on objective or subjective data evaluated by the clinician.

Note 3 to entry: Can be qualified by site (3.3.3) , and measure (3.3.12) for example, movement of leg, tissue integrity of left heel, size of wound.

3.7.2

medical diagnosis

determination of which disease or condition explains a person’s signs and symptoms

Note 1 to entry: Provisional diagnosis may change during the episode of care and may be coded based on the ICD terminology.

3.7.3

treatment impact

causal effect of the chosen set of all clinical actions (treatment) undertaken by teams of health professionals on an outcome

Note 1 to entry: Treatment options usually have evidence-based protocols or clinical guidelines.

3.7.4

confounding factor

third variable that might have contributed to the primary cause and effect relationship

3.7.5

supply availability

provision of necessary, surgical, linen, nutritional or medication supplies at the time and location when required to support an action

3.7.6

local environment

prevailing circumstances, locality and setting that support or hinder nursingActions (3.4.1) to be taken

Note 1 to entry: Environment refers to physical, social and/or cultural phenomena, including medical dominance, organizational culture, entity specific ethical, philosophical or moral determinants.

Note 2 to entry: This also includes social determinants.

3.7.7

scheduling issues

match between required additional services and subject of care (3.2.2) needs

Note 1 to entry: Human resources and specialist services, such as a diagnostic test or specialist treatment option availability. Non-availability when required influences nursing action (3.4.1) .

3.7.8

tool availability

provision of desirable or necessary equipment or devices required to support action

Note 1 to entry: Tools include lifting machines, alternating pressure mattresses, IV pumps, monitors.

3.7.9

risk minimization

initiatives taken or omitted to be taken as strategies to positively influence subject of care (3.2.2) or provider actions known to minimize or prevent harm

Note 1 to entry: Many nursing action (3.4.1) are designed to prevent harm based on known evidence-based risk minimization actions documented in, for example, procedure manuals.

Note 2 to entry: A risk is a potential for a negative diagnosis, an opportunity (or chance) is a potential for a positive diagnosis.

3.7.10

healthcare provider

person or organization who is involved in, or associated with, or has the responsibility for the delivery of healthcare to a client, subject of care (3.2.2) or caring for client wellbeing

3.7.11

human resource management

coordinated activity by organisational care provider to realize value from its human resource assets

Note 1 to entry: Nurses have variable specialist qualifications and experience (skill mix) which need to be matched with service demand in terms of number of nurses, their collective capacity and registered scope of practice. Care teams also rely on the availability of various non-nursing support services, such as porters, cleaners.

3.7.12

self-care behaviour

decisions and actions taken by the subject of care (3.2.2) who is, has been or will be the recipient of care services or by their associated individual (3.2.5)

3.7.13

social determinant

condition relative to the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks