Belgium lacks a common terminology for documenting nursing care across hospitals, residential care, psychiatric services and home care. Different organisations use different systems and terminologies, creating risks when information is transferred between institutions. SNOMED CT offers a basis for a shared nursing reference set because it supports structured documentation and semantic interoperability. The aim was to identify the SNOMED CT concepts needed to standardise nursing documentation across care settings in Belgium.
Scope and Development Approach
The reference set was built around a five-step nursing process: assessment, diagnosis, planning, implementation and evaluation. Assessment covered clinical measurements, symptoms and patient experiences from the patient and the surrounding environment. Diagnosis focused on clinical judgement and prioritisation of collected information. Planning addressed goals and outcomes, implementation covered planned interventions and actions, and evaluation reviewed whether goals had been met and whether care plans needed adjustment. This process guided concept selection by defining which parts of nursing care needed to be represented.
The intended scope was broad. The reference set aimed to support nursing documentation in hospital care, home care and nursing home care, and across clinical disciplines such as paediatrics, psychiatry, cardiology, orthopaedic surgery and intensive care. The target users were nurses delivering care across these settings, with the expectation that they should be able to document the full nursing process at the point of care.
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Development followed the SNOMED CT method of adapting an existing reference set. Seven standardised nursing languages were examined for number of concepts, structure, intended users, mapping to SNOMED CT, update frequency and practical advantages or disadvantages. A guidance committee of five members monitored design and content throughout the process.
Choosing the Reference Languages
The seven standardised nursing languages examined were NANDA-I, NIC, NOC, ICNP, ICF, CCC and the Omaha System. Two were excluded because they were not nurse specific. The Omaha System and ICF target broader groups of healthcare professionals, which reduced their suitability for a nursing-focused reference set. The remaining five then underwent face validity testing to assess whether they covered important aspects of nursing care, offered enough detail and used a logical structure.
NANDA-I, NIC and NOC together provided diagnoses, interventions and outcomes needed to describe nursing care, but they relied on lower-level concepts to achieve sufficient detail. That would have required mapping more than 10,000 concepts to SNOMED CT, which was not feasible within the project scope. ICNP and CCC proved more practical. ICNP offered detailed concepts that could describe nursing care through an existing equivalence table with SNOMED CT. CCC contributed a structured framework based on 21 care components and included nursing diagnoses, interventions and outcomes focused on nursing care across settings.
CCC was fully mapped to SNOMED CT without null mappings and offered a structure that could organise the reference set. ICNP added the detail needed to further specify diagnoses, interventions and outcomes. Together, CCC and ICNP formed the evidence-based foundation for the Belgian nursing reference set.
Final Set and Remaining Work
The mapping from ICNP yielded 2035 SNOMED CT concepts and the mapping from CCC yielded 979. After alternatives were sought for null mappings, 23 ICNP concepts still had no mapped SNOMED CT concept and were excluded. Duplicate target concepts from the two systems were then removed, eliminating 376 concepts. A further five SNOMED CT concepts were excluded because their clinical meaning was considered too broad and therefore open to misinterpretation in practice. After screening, the final theoretical framework contained 2633 unique SNOMED CT concepts intended to support nursing documentation across different care settings.
Further refinement remains necessary. Clinical experts from different nursing domains need to validate the framework by adding relevant concepts and removing irrelevant ones. Translation into Dutch and French is also required to support implementation in Belgium and reduce the risk of local variation in use. Future maintenance should expand coverage across the full spectrum of nursing care, including acute care, long-term care, home care, paediatrics and mental health. Continued collaboration with SNOMED International, the National Release Center for SNOMED CT and the Belgian Terminology Center will support updates and integration into electronic health record systems.
The Belgian nursing reference set provides an evidence-based starting point for standardising nursing documentation in SNOMED CT. By combining CCC and ICNP, it brings together a structured nursing framework and more detailed clinical terminology, resulting in 2633 unique SNOMED CT concepts. The work addresses the absence of a common nursing terminology in Belgium and aims to support clearer exchange and reuse of nursing documentation across care settings. Its value now depends on further refinement, clinical validation, translation and ongoing maintenance.
Source: Health Informatics Journal
Image Credit: iStock
References:
Thys J, Balcaen K, Vanpee G & D’Havé A (2026) Development of an evidence-based foundation for a Belgian nursing reference set in SNOMED CT. Health Informatics Journal; 32(1): Online first.
