Contributions of representing the elements of nursing practice in the ISO 18.104:2023 standard: a theoretical study.
Marcia Regina Cubas, Rudval Souza da Silva, Cândida Caniçali Primo and 3 others
PMID 38587403WHAT IT FOUND
The updated ISO 18.104:2023 standard clarifies how to record nursing practice in electronic systems.
It defines how to link nursing diagnoses to specific actions and outcomes, and states that a nursing diagnosis can indicate the complexity of care required.
Key findings
01The standard defines the relationship between nursing diagnosis, action, and outcome to support electronic documentation.
02A nursing diagnosis is now explicitly described as an indicator of nursing service demand.
03The standard uses mind maps to show how nursing actions and outcomes are linked to various causes, such as environment and treatment impact.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
This is a theoretical analysis of a standard's text, not a study of clinical practice or patient outcomes. The authors note that the literal translation of 'nurse sensitive outcome' is difficult in Portuguese, which may affect how the concept is understood in non-English contexts. The standard does not clarify how care prescriptions should be recorded, as the verb tense guidance applies to completed actions.
Declared interests
The study was supported by the Brazilian National Council for Scientific and Technological Development (CNPq) and Edital ProForte UNEB.
The easy way to misread this
Do not interpret this as evidence that using the ISO 18.104:2023 standard improves patient care or clinical outcomes. The paper only describes the structure and definitions within the standard itself, not its effect on practice.