AHCPR Conference Center
Rockvillle, MD, May 17-18, 1999
Written testimony
for
Presentation By
Virginia K. Saba, EdD, RN, FAAN, FACMI
Distinguished Scholar / Developer
Georgetown University
Washington, DC
As the developer of the Home Health Classification System (HHCC), I appreciate this opportunity to submit written comments and testify to the National Committee on Vital and Health Statistics (NCVHS) -- Work Group on Computer-based Patient Records. The HHCC System can be used to assist and advise the Secretary of Health and Human Services in “ the adoption of a uniform data standards for patient medical record information and the electronic exchange of such information” for the implementation of the Health Insurance Portability and Accountability Act (HIPAA) of 1996.
To-date, the information presented to the NCVHS and reported in the literature clearly indicate that “PATIENT CARE DATA” represent the largest gap in the existing health care databases. Further, the federally approved terminologies used to record medical information are primarily designed to code disease conditions and/or procedures. These terminologies do not address the CARE of patients, regardless of setting; and as a result, CARE data are not generally collected by CPR systems. However, to support future PMRI requirements, the CPR Systems must include patient CARE data to determine costs, assess quality, and evaluate outcomes.
At this time, the Home Health Care Classification (HHCC) System is available and can be used to document and code patient CARE data primarily for the home health industry. It consists of two interrelated terminologies -- HHCC of Nursing Diagnoses and HHCC of Nursing Interventions -- classified by twenty care components (20 CCs) that represent the Physiological, Psychological, Functional, and Health Behaviors Patterns of patient CARE. (See Appendix A). The 20 CCs also serve as a uniform framework for mapping the two interrelated HHCC terminologies to each other and to other medical terminologies (Saba, 1995; Saba & Sparks, 1998).
The major reasons why the HHCC System differ from the other American Nurses Association (ANA) ?Recognized’ nursing terminologies and should be considered for implementation for the HIPAA legislation are listed below.
The two HHCC Terminologies of Nursing Diagnoses and Nursing Interventions:
Thus, The HHCC System with the two interrelated terminologies, can be used to code, index, classify; as well as, document, track, and measure home health patient CARE over time for the episode of illness and/or wellness. That includes:
Thus, CARE provided over time can not only be cost effective, but also can address quality and evaluate outcomes.
As the NCVHS -- Work Group on Computer-based Patient Records consider medical and clinical specific code set issues surrounding implementing the HIPAA requirements, I am providing the following responses to specific questions posed by the Committee.
1. DEFINITIONS AND REQUIREMENTS FOR PATIENT MEDICAL RECORD INFORMATION (PMRI): HOW WOULD DEFINE OR DESCRIBE PMRI?
The newest definition for the Patient Medical Record Information is the one defined by Dick and Steen (1991) in the Institute of Medicine (IOM) report on the Computer- based Patient Record (CPR) as: “The patient record is the repository of information about a single patient. The information is generated by health care professionals as a direct result of interaction with a patient or with individuals who have personal knowledge of the patient(or with both). Traditionally, patient records have been paper and have been used to store patient care data” (p.11). In 1996, Chute and colleagues further stated in their writings that “patient conditions and events are the core of patient record content” (p.224).
However, the above PMRI definitions have to be expanded to address the electronic exchange requirements for implementing HIPAA. The CPR is defined by Dick and Steen (1991) in the IOM report as: “an electronic patient record that resides in a system specifically designed to support users by providing accessibility to complete and accurate data, alerts, reminders, clinical decision support systems, links to medical knowledge, and other aids” (p.11). Where as, Chute and colleagues (1996) defined the CPR as those patient records which: “ .. will require standard vocabularies to represent these data consistently, thereby facilitating clinical decision support, research, and efficient care delivery” (p. 224).
These two definitions complement each other and both are needed to support the CPR requirements for implementing HIPAA.
A. Why is comparable PMRI required, what functions does it serve?
Comparable PMRI are critical and essential for any CPR to have continuity across the continuum of care. Comparable, reliable, and timely data are needed to describe the health status of the patient population for specific episodes of illness. However, to achieve comparability, two major problems with the PMRI found in the existing CPR need to be resolved. The first, is a need to code and collect patient CARE data for an episode of illness. And the second, is a need for a uniform framework to map medical diagnostic, therapeutic, and other health-related terminologies including a CARE terminology.
A patient CARE terminology is critical for any CPR to capture the complete CARE process. Also, a framework is needed so that the different health care professionals using different terminologies can communicate with each other over time within and across health care settings, geographic boundaries, and population groups. Uniform data standards for the CPR could ensure valid and reliable data, as well as reduce costs of data collection. Such a framework could be used to guide and support health policy formulation, program planning, management, as well as measure the outcomes of the CARE.
B. How comparable does the PMRI need to be for these purposes, i.e., how precise, how accurate? What are the consequences if the PMRI in not accurate?
The precision of the terminologies vary depending on the usage of the data. If patient CARE data is collected based on a uniform data standard framework, then the data could be used to identify resources, determine costs and payments, report statistics, and evaluate outcomes. Several research studies have indicate that 99% compliance is easily achieved with a framework for mapping terminologies and is sufficient for generating such required information. Further, since health care is an art as well as a science, than it is unrealistic to think that a CPR could or should achieve 100 percent precision.
2. THE ROLE OF THE HOME HEALTH CARE CLASSIFICATION (HHCC) CODE SET / TERMINOLOGY PLAYS IN REPRESENTING PMRI?
A. What is the intended purpose of the the HHCC terminology? What is it currently used for?
B. What is the clinical domain, scope, or healthcare setting addressed by the HHCC’s terminologies?
The Home Health Care Classification (HHCC) System can play a major role in representing PMRI in the CPR. It can be used specifically to document PMRI including patient CARE for the home health and community health settings.
The HHCC System consists of two separate but interrelated terminologies -- HHCC of Nursing Diagnoses and HHCC of Nursing Interventions -- which are both classified by 20 Care Components (CCs) that represent the Physiological, Psychological, Functional, and Health Behaviors patterns of clinical CARE. (See Appendix A). The 20 CCs also serve as a uniform data standard framework for mapping the terminologies to each other and to other medical and health related terminologies (Saba, 1994, 1997).
These two HHCC terminologies are designed not only to code, index, and classify; as well as, document, track, and measure home health CARE for a patient over time for an episode of illness. Specifically, they are used to: (a) Assess and diagnose patient CARE needs on admission; (b) Track CARE provided -- DURING and BETWEEN -- home health visits; and (c) Evaluate CARE Outcomes on Discharge for the episode of illness.
The HHCC of Nursing Diagnoses terminology consists of 145 (50 two digit major categories and 95 three digit subcategories) that depicts nursing diagnoses and/or patient problems. The HHCC of Nursing Interventions terminology consists of 160 (60 two digit major categories and 100 three digit subcategories) that depicts nursing interventions, procedures, activities and/or services.
The two terminologies also use modifiers to expand each code to represent a different level or axis for a patient problem and/or intervention. The HHCC of Nursing Diagnosis Terminology is expanded by using three modifiers (Improved, Stabilized, Deteriorated) to code the expected / actual outcomes in order to compare and evaluate them as outcomes of CARE. (This additional coded digit increased the number of the HHCC of Nursing Diagnoses terms from 145 to 435 terms [145 x 3]). The HHCC of Nursing Interventions Terminology is expanded by using four modifiers (Assess, Care, Teach, Manage) to code the type intervention action in order to identify the different types of action -- DURING and BETWEEN -- home health visits. It has been proven that types of intervention actions does impact on resources needed, cost of a visit, and quality of the CARE provided. (The additional coded digit increased the number of the HHCC of Nursing Interventions terms from 160 to total 640 [160 x 4]).
A. What evidence do you have of market acceptance of the HHCC terminology? (Ask users what their perceptions of gaps are)
The home health industry consists of approximately 10,000 Medicare certified home health agencies (HHAs) who are providers of home health services to Medicare recipients. Also, there are thousands of health-related facilities such as outpatient clinics, health maintenance organizations (HMOs) and other community health settings that may offer similar services who are not Medicare certified (NAHC, 1998).
To date, the two interrelated HHCC terminologies with the 20 CCs have been used by a large number of HHAs as well as by commercial developers of home health CPR systems to record and code patient CARE. They have been used separately or together to document and code patient CARE plans or protocols. Since the HHCC system is in the public domain and available on the Internet <http//:www.dml.georgetown.edu/research/hhcc>, it can be downloaded without permission. As a result, it is not possible to determine who and how many commercial vendors and/or HHAs are using the two HHCC terminologies with the 20 CCs separately or together.
Several HHAs and/or commercial vendors have indicated that they do use the two interrelated HHCC terminologies with the 20 CCs to map to the medical, disease, and/or clinical procedure terminologies required by the federal government. Others have indicated that they are using selected CCs or Nursing Interventions to document and cost out specific nursing services.
Also, evidence has been presented by several researchers who have conducted studies using the two interrelated HHCC terminologies with the 20 CCs, that the 20 CCs are 99% compliant with the other terminologies used by primary care providers who document and code medical conditions and/or procedures using other medical terminologies (Henry, Warren, Lange, & Button, 1998).
B. In what areas are you now planning to expand to other medical terminologies?
The next release of the HHCC System currently in progress is to expand the coding strategy to track patient CARE -- DURING and BETWEEN -- home health visits. The new innovative coding system is being tested on specific patient problems for an episode of illness. Documenting and Coding CARE -- DURING and BETWEEN -- home health visits has never been addressed by the HHAs and/or commercial vendors.. This coding strategy is envisioned to form the basis for a CPR that could be used to track patient CARE in order to identify resources, determine costs, and evaluate outcomes.
Another envisioned release is to expand the two interrelated HHCC Terminologies with the 20 CCs to encompass the scope of services provided by Primary Care Providers (PCPs) -- clinicians, physicians, physician assistants, nurse practitioners (NPs), and other advanced practice nurses (APNs). Since the PCPs function in the all health care settings -- home health, community, and ambulatory care -- we are studying the new services they provide to develop and expand the terminologies. Currently, the non-physician NP providers utilize only the coded terminologies used by physicians for reimbursement; and generally, omit and exclude patient CARE which does not have a reimbursable coded terminology.
3. HOW DOES the HHCC TERMINOLOGY RELATE TO OTHER MEDICAL TERMINOLOGIES?
The two interrelated HHCC terminologies -- Nursing Diagnoses and Nursing Interventions with the 20 CCs are related to other medical terminologies in several ways, eight of which, are described below:
A. ICD-10
The HHCC System is related to iCD-10 (International Statistical Classification of Diseases and Related Health Problems) since the two interrelated HHCC terminologies -- Nursing Diagnoses and Nursing Intervention classified by the 20 CCs -- are coded similar to the ICD-10 five-character alphanumeric coding structure (WHO, 1990). By using the ICD-10 coding structure, the two HHCC terminologies can be mapped to medical diagnostic codes required by the federal regulators for the reimbursement of services provided to home health Medicare patients. The ICD-10 is being federally mandated to replace ICD-9 as the coding scheme for federal recipients of services by the year 2001.
The coding structure for either terminology consists of a first character -- an alphabetic code representing the ?Care Component’ followed by two numeric digits -- "major category" than a decimal point followed by a fourth numeric digit -- "subcategory" and a fifth digit -- "modifier".
B. HCFA HHA Form: 486
The HHCC System is also related the HCFA -486 - Home Health Medical Update Form which is the Form that must be completed by the nurse and/or therapist on admission to "prospectively" identify the nursing and other services that would be provided to the patient during the episode of illness. The Form which also includes a Medical Diagnosis and once approved by a Physician, allows the HHA providers to make home health visits that can be reimbursed payment by Medicare and/or third-party payers. However, the home health visits have to include only the visits for services from a "The List of 32 Treatment Codes for Professional Services Required for Skilled Nursing." The HCFA List of 32 Treatnent Codes are incorporated in the HHCC of Nursing Interventions Terminology and represent only a fraction of the 640 HHCC of Nursing Interventions found to represent the home health Industry (Saba & McCormick, 1996).
C. OASIS
The two HHCC terminologies with the 20 CCs complement the Outcome and ASessment Information Set (OASIS) data set (Shaughnessy, Crisler, & Schienker, 1997). The 79 OASIS quality indicators are being required by HCFA as the new Conditions of Participation for HHAs for services to Medicare recipients. OASIS is not a terminology but a set of indicators designed to comprehensively assess health status and care needs of patients in order to measure outcome-based quality improvement. Note that OASIS does not preclude the use of a terminology but rather it facilitates the need for the two interrelated HHCC terminologies to document and track home health patient CARE -- DURING and BETWEEN -- home health visits for an episode of illness.
D. NANDA Taxonomy I
The HHCC of Nursing Diagnosis does relate to the North American Nursing Diagnoses, NANDA Taxonomy I Revised (NANDA, 1991) which consisted of 104 NANDA approved Nursing Diagnoses and which were coded similar to ICD-10. The HHCC of Nursing Diagnoses have adapted and expanded Taxonomy I to include over 50 new home health diagnostic terms derived from the 40,000 statements collected by the Georgetown Home Care research study from which the HHCC of Nursing Diagnoses terminology was developed. The adapted NANDA terms were also restructured as noun phrases instead verb clauses making them unique and different from the NANDA labels.
E. Unified Medical Language System
The two HHCC terminologies with the 20 CCs have been included in the Unified Medical Language System (UMLS) Metathesaurus database (NLM, 1999). In 1994, they were submitted to the NLM by the American Nurses Association as professionally ?recognized’ source vocabularies; and therefore, were eligible for inclusion into this massive national database. "The Metathesaurus is organized by concept or meaning. In essence, its purpose is to link alternative names and views of the same concept together and to identify useful relationships between different concepts" (p. 5) . Thus, the terms from the two HHCC terminologies including the 20 CCs are mapped to all other medical terminologies that represent similar concepts.
F. CINAHL Subject Heading List
The two HHCC terminologies with the 20 CC are also indexed in the Cumulative Index for Nursing and Allied Health Literature’s CINAHL Subject Heading List (Cinahl Information Systems ( 1998). The CINAHL database is a bibliographic database which contains of abstracts and/or full text of nursing and related allied health literature in a machine-readable format and organized for retrieval and analysis. The two HHCC terminologies with the 20CCs are indexed as search terms to the nursing and allied health literature (CINAHL Database Thesaurus, 1998).
G. Foreign Translations
The two HHCC terminologies with the 20CCs have been integrated into several European terminologies as well as translated in several of the European languages -- Finnish, Dutch, and Portugese.
H. European Terminology Efforts
The two HHCC terminologies with the 20 CCs also have been integrated into at least two European terminology /vocabulary efforts. The first is the TELENURSE project being conducted by the Danish Institute for Health and Nursing Research, Copenhagen, Denmark. This project is focusing on developing a uniform standard CPR for nursing terminologies for the nursing organizations in the European Union member countries (Mortensen and colleagues (1994).
The second, is the International Classification of Nursing Practice (ICNP) under development by the International Council of Nurses (ICN) in Geneva, Switzerland (Mortensen & Nielsen 1996). Since 1998 the ICN has been collecting nursing terminologies and vocabularies from its members (national nursing organizations from Europe and around the world). The ICN research team are mapping and integrating the terminologies and/or vocabularies into a unique uniform ICNP . At this time, the ICNP is in its second generation and is still evolving. Once it is approved by all the 128 ICN member nations, then ICN plans submit it to the World Health Organization for consideration as a member of the ICD-10 family of disease and health-related classifications (WHO, 1990 p. 21). .
4. HOW DOES HHCC TERMINOLOGIES RELATE TO HEALTHCARE MESSAGE FORMAT STANDARDS?
A. Which message format standards reference or include the HHCC
The two HHCC terminologies with the 20 CCs have been approved as complying with at least three format standards. They comply with: (a) the Health Level 7 electronic transaction standards; (2) ICD-10 coding structure; and (c) the American Nurses Association (ANA) Information and Data Set Evaluation Center (NIDSEC) standards. NIDSEC was established “to develop and disseminate standards pertaining to information systems that support the documentation of nursing practice and to evaluate voluntarily submitted information systems against these standards” (NIDSEC, 1997, p.iv).
B. Is the use of your medical terminology within these message format standards required, preferred, or optional?
All of the format standards are optional since Nursing CARE is not required in any of the federally mandated terminologies. However, NIDSEC does recommend that any health-related CPR System include an approved ANA should include a nursing terminology such as the two HHCC terminologies with the 20 CCs.
5. ARE THERE ISSUES RELATED TO MEDICAL TERMINOLOGIES THAT DESERVE GOVERNMENT ATTENTION OR ACTION?
YES! The federal government should consider expanding reimbursement for specific patient CARE in the home health and community health care settings. The current Medicare reimbursement policy for HHAs services for Medicare recipients is based on a medical diagnosis with related home visits prospectively determined and approved for 60 day certification time intervals. Reimbursement is NOT based on the assessment of a patient problem (nursing diagnosis) nor on the specific patient CARE (services) provided -- DURING and BETWEEN -- home health visits during an episode of illness. Thus, it is imperative that the federal government approve of a terminology to document and code patient care and approve of the reimbursement of patient CARE services. Such CARE data can ensure continuity across the continuum of health care.
Further, it is imperative that the federal government support measures to develop uniform data standard framework so that the existing health care terminologies and/or coding strategies can be mapped. Even though CPR systems have existed for over 30 years, we do not have any federally mandated data standards to implement the scope and intent of the PMRI .
B. What can be done to address these issues in a one-to four-year time frame?
The two HHCC terminologies with the 20 CCs were developed from the HCFA funded Georgetown University Home Care Project. They could be used to develop a CPR that can track patient CARE -- DURING and BETWEEN -- home health visits for an episode of illness. Such a CPR could be also used to: (a) assess CARE needs, (b) measure CARE services, (c) evaluate CARE outcomes, and (d) calculate CARE costs for the Home Health Industry (Saba, 1997).
A federal contract or cooperative agreement could be initiated with the Georgetown HHCC research team to conduct the proposed is possible. It CPR could focus on CARE protocols for the identified top ten medical diagnostic conditions of home health Medicare patients. The contract could be designed to compare the three strategies: (a) the traditional method of reimbursement (HCFA Form 486, (b) the OASIS quality indicators, and (c) the proposed patient CARE --DURING and BETWEEN -- home health visits using the two HHCC terminologies with the 20 CCs. Such a scope of work could be accomplished within a two year time frame.
6. ARE THERE ISSUES RELATED TO THE COMPARABILITY OF THE PMRI?
A. If so, what should the role of the government?
YES I anticipate that issues will emerge regarding the reimbursement of Primary Care Providers including non-physician providers -- Nurse Practitioners, Physician Assistants and other Advanced Practice Nurse Clinicians in all types of health care settings; and more specifically, in the wide range on community health settings such as ambulatory care settings, health maintenance organizations (HMOs), rural health clinics, etc. Further, what the PCPs should use to code and to be reimbursed not only for their diagnostic procedure, therapeutic regimes, but also for Patient CARE Services they provide.
B Is there a need for increased coordination among terminology developers? If so what type?.
As a developer of the HHCC System, it is critical that the terminology developers consider implementing a uniform data standard framework for all the coded terminologies to be mapped. Such a framework could serve as the umbrella structure used to track the continuity of CARE in and across health care settings, geographic locations, and population groups where medical services are provided.
C. Is there a need to coordinate between terminology developers and message standard developers? What type or form should it take?
YES! There is a need to coordinate between terminology developers and message standard developers. To accomplish such a task the federal government should fund an initiative to develop uniform data standard framework.
D. In the short run (1-4 years) and long run (5-10years)?
YES. I believe in the short run a data standard framework for the mapping all health care terminologies in the field of home health could be addressed. The framework should on the “whole sick patient and/or well client”. At this time, the existing terminologies used focus primarily on the disease conditions of body systems and/or surgical procedures. They do not address the patient CARE process of the whole patient/client during an episode of illness.
In the short and long term, the home health setting could be the primary setting that could be use to research patient CARE. The two HHCC terminologies with the 20 CCs could be used to test several areas: (a) test the CPR strategy for measuring patient CARE services -- DURING and BETWEEN -- home health visits; (b) test home health CARE protocols for an episode of illness; (c) test the uniform data standard framework for home health CARE; and (d) measure, costs, quality, and outcomes of patient CARE for an episode of home health illness.
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A complete description of the HHCC of Nursing Diagnoses and Nursing Interventions with the 20 Care Components including their definitions are available on the Internet
http://www.dml.georgetown.edu/research/hhcc
HOME HEALTH CARE CLASSIFICATION (HHCC) SYSTEM
Under Revision
By
Distinguished Scholar
Georgetown University
Washington, DC
May, 1999
Table 1. Home Health Care Classification - 20 Nursing Components: Alphabetic Index and Codes
Coding structure for Home Health Care Classification (HHCC) of Nursing Diagnoses and Expected Outcomes/Goals. The coding structure consists of five alphanumeric characters.
Table 2: Home Health Care Classification of Nursing Diagnoses and Coding Scheme: 50 Major Categories and 95 Subcategories.
01 Activity Alteration
01.1 Activity Intolerance
01.2 Activity Intolerance Risk
01.3 Diversional Activity Deficit
01.4 Fatigue
01.5 Physical Mobility Impairment
01.6 Sleep Pattern Disturbance
02 Musculoskeletal Alteration
03 Bowel Elimination Alteration
03.1 Bowel Incontinence
03.2 Colonic Constipation
03.3 Diarrhea
03.4 Fecal Impaction
03.5 Perceived Constipation
03.6 Unspecified Constipation
04 Gastrointestinal Alteration
05 Cardiac Output Alteration
06 Cardiovascular Alteration
06.1 Blood Pressure Alteration
07 Cerebral Alteration
08 Knowledge Deficit
08.1 Knowledge Deficit of Diagnostic Test
08.2 Knowledge Deficit of Dietary Regimen
08.3 Knowledge Deficit of Disease Process
08.4 Knowledge Deficit of Fluid Volume
08.5 Knowledge Deficit of Medication Regimen
08.6 Knowledge Deficit of Safety Precautions
08.7 Knowledge Deficit of Therapeutic Regimen
09 Thought Processes Alteration
10 Dying Process
11 Family Coping Impairment
11.1 Compromised Family Coping
11.2 Disabled Family Coping
12 Individual Coping Impairment
12.1 Adjustment Impairment
12.2 Decisional Conflict
12.3 Defensive Coping
12.4 Denial
13 Post-Trauma Response
13.1 Rape Trauma Syndrome
14 Spiritual State Alteration
14.1 Spiritual Distress
15 Fluid Volume Alteration
15.1 Fluid Volume Deficit
15.2 Fluid Volume Deficit Risk
15.3 Fluid Volume Excess
15.4 Fluid Volume Excess Risk
16 Growth and Development Alteration
17 Health Maintenance Alteration
18 Health Seeking Behavior Alteration
19 Home Maintenance Alteration
20 Noncompliance
20.1 Noncompliance of Diagnostic Test
20.2 Noncompliance of Dietary Regimen
20.3 Noncompliance of Fluid Volume
20.4 Noncompliance of Medication Regimen
20.5 Noncompliance of Safety Precautions
20.6 Noncompliance of Therapeutic Regimen
21 Medication Risk
21.1 Polypharmacy
22 Endocrine Alteration
23 Immunologic Alteration
23.1 Protection Alteration
24 Nutrition Alteration
24.1 Body Nutrition Deficit
24.2 Body Nutrition Deficit Risk
24.3 Body Nutrition Excess
24.4 Body Nutrition Excess Risk
25 Physical Regulation Alteration
25.1 Dysreflexia
25.2 Hyperthermia
25.3 Hypothermia
25.4 Thermoregulation Impairment
25.5 Infection Risk
25.6 Infection Unspecified
26 Respiration Alteration
26.1 Airway Clearance Impairment
26.2 Breathing Pattern Impairment
26.3 Gas Exchange Impairment
27 Role Performance Alteration
27.1 Parental Role Conflict
27.2 Parenting Alteration
27.3 Sexual Dysfunction
28 Communication Impairment
28.1 Verbal Impairment
29 Family Processes Alteration
30 Grieving
30.1 Anticipatory Grieving
30.2 Dysfunctional Grieving
31 Sexuality Patterns Alteration
32 Socialization Alteration
32.1 Social Interaction Alteration
32.2 Social Isolation
N - SAFETY COMPONENT
33 Injury Risk
33.1 Aspiration Risk
33.2 Disuse Syndrome
33.3 Poisoning Risk
33.4 Suffocation Risk
33.5 Trauma Risk
34 Violence Risk
O - SELF-CARE COMPONENT
35 Bathing/Hygiene Deficit
36 Dressing/Grooming Deficit
37 Feeding Deficit
37.1 Breastfeeding Impairment
37.2 Swallowing Impairment
38 Self Care Deficit
38.1 Activities of Daily Living (ADLs) Alteration
38.2 Instrumental Activities of Daily Living (IADLs)Alteration
39 Toileting Deficit
40 Anxiety
41 Fear
42 Meaningfulness Alteration
42.1 Hopelessness
42.2 Powerlessness
43 Self Concept Alteration
43.1 Body Image Disturbance
43.2 Personal Identity Disturbance
43.3 Chronic Low Self-Esteem Disturbance
43.4 Situational Self-Esteem Disturbance
44 Sensory Perceptual Alteration
44.1 Auditory Alteration
44.2 Gustatory Alteration
44.3 Kinesthetic Alteration
44.4 Olfactory Alteration
44.5 Tactile Alteration
44.6 Unilateral Neglect
44.7 Visual Alteration
45 Comfort Alteration
45.1 Acute Pain
45.2 Chronic Pain
45.3 Unspecified Pain
46 Skin Integrity Alteration
46.1 Oral Mucous Membranes Impairment
46.2 Skin Integrity Impairment
46.3 Skin Integrity Impairment Risk
46.4 Skin Incision
47 Peripheral Alteration
48 Tissue Perfusion Alteration
49 Urinary Elimination Alteration
49.1 Functional Urinary Incontinence
49.2 Reflex Urinary Incontinence
49.3 Stress Urinary Incontinence
49.4 Total Urinary Incontinence
49.5 Urge Urinary Incontinence
49.6 Urinary Retention
50 Renal Alteration
1 Adapted from NANDA: Taxonomy I: Revised 1990.
Coding structure for the Home Health Care Classification of Nursing Interventions and Type Intervention Action. The coding structure consists of five alphanumeric characters.
Table 3: Home Health Care Classification of Nursing Interventions and Coding Scheme: 60 Major Categories & 100 Subcategories.
01 Activity Care
01.1 Cardiac Rehabilitation
01.2 Energy Conservation
02 Fracture Care
02.1 Cast Care
02.2 Immobilizer Care
03 Mobility Therapy
03.1 Ambulation Therapy
03.2 Assistive Device Therapy
03.3 Transfer Care
04 Sleep Pattern Control
05 Rehabilitation Care
05.1 Range of Motion
05.2 Rehabilitation Exercise
06 Bowel Care
06.1 Bowel Training
06.2 Disimpaction
06.3 Enema
07 Ostomy Care
07.1 Ostomy Irrigation
08 Cardiac Care
09 Pacemaker Care
10 Behavior Care
11 Reality Orientation
12 Counseling Service
12.1 Coping Support
12.2 Stress Control
13 Emotional Support
13.1 Spiritual Comfort
14 Terminal Care
14.1 Bereavement Support
14.2 Dying/Death Measures
14.3 Funeral Arrangements
15 Fluid Therapy
15.1 Hydration Status
15.2 Intake/Output
16 Infusion Care
16.1 Intravenous Care
16.2 Venous Catheter Care
17 Community Special Programs
17.1 Adult Day Center
17.2 Hospice
17.3 Meals-on-Wheels
17.4 Other Community Special Program
18 Compliance Care
18.1 Compliance with Diet
18.2 Compliance with Fluid Volume
18.3 Compliance with Medical Regime
18.4 Compliance with Medication Regime
18.5 Compliance with Safety Precautions
18.6 Compliance with Therapeutic Regime
19 Nursing Contact
19.1 Bill of Rights
19.2 Nursing Care Coordination
19.3 Nursing Status Report
20 Physician Contact
20.1 Medical Regime Orders
20.2 Physician Status Report
21 Professional/Ancillary Services
21.1 Home Health Aide Service
21.2 Medical Social Worker Service
21.3 Nurse Specialist Service
21.4 Occupational Therapist Service
21.5 Physical Therapist Service
21.6 Speech Therapist Service
21.7 Other Ancillary Service
21.8 Other Professional Service
22 Chemotherapy Care
23 Injection Administration
23.1 Insulin Injection
23.2 Vitamin B12 Injection
24 Medication Administration
24.1 Medication Actions
24.2 Medication Prefill Preparation
24.3 Medication Side Effects
25 Radiation Therapy Care
26 Allergic Reaction Care
27 Diabetic Care
28 Gastrostomy/Nasogastric Tube Care
28.1 Gastrostomy/Nasogastric Tube Insertion
28.2 Gastrostomy/Nasogastric Tube Irrigation
29 Nutrition Care
29.1 Enteral/Parenteral Feeding
29.2 Feeding Technique
29.3 Regular Diet
29.4 Special Diet
30 Infection Control
30.1 Universal Precautions
31 Physical Health Care
31.1 Health History
31.2 Health Promotion
31.3 Physical Examination
31.4 Physical Measurements
32 Specimen Analysis
32.1 Blood Specimen Analysis
32.2 Stool Specimen Analysis
32.3 Urine Specimen Analysis
32.4 Other Specimen Analysis
33 Vital Signs
33.1 Blood Pressure
33.2 Temperature
33.3 Pulse
33.4 Respiration
34 Weight Control
35 Oxygen Therapy Care
36 Respiratory Care
36.1 Breathing Exercises
36.2 Chest Physiotherapy
36.3 Inhalation Therapy
36.4 Ventilator Care
37 Tracheostomy Care
38 Communication Care
39 Psychosocial Analysis
39.1 Home Situation Analysis
39.2 Interpersonal Dynamics Analysis
40 Abuse Control
41 Emergency Care
42 Safety Precautions
42.1 Environmental Safety
42.2 Equipment Safety
42.3 Individual Safety
43 Personal Care
43.1 Activities of Daily Living (ADLs)
43.2 Instrumental Activities of Daily Living (IADLs)
44 Bedbound Care
44.1 Positioning Therapy
45 Mental Health Care
45.1 Mental Health History
45.2 Mental Health Promotion
45.3 Mental Health Screening
45.4 Mental Health Treatment
46 Violence Control
47 Pain Control
48 Comfort Care
49 Ear Care
49.1 Hearing Aid Care
49.2 Wax Removal
50 Eye Care
50.1 Cataract Care
51 Decubitus Care
51.1 Decubitus Stage 1
51.2 Decubitus Stage 2
51.3 Decubitus Stage 3
51.4 Decubitus Stage 4
52 Edema Control
53 Mouth Care
53.1 Denture Care
54 Skin Care
54.1 Skin Breakdown Control
55 Wound Care
55.1 Drainage Tube Care
55.2 Dressing Change
55.3 Incision Care
56 Foot Care
57 Perineal Care
58 Bladder Care
58.1 Bladder Instillation
58.2 Bladder Training
59 Dialysis Care
60 Urinary Catheter Care
60.1 Urinary Catheter Insertion
60.2 Urinary Catheter Irrigation