国际护理实践分类在骨科护理记录结构化分析中的应用研究

[摘要] Abstract：Objective To investigate the feasibility of the international classification (ICNP version 2.0) of nursing practice for structural analysis of electronic nursing records. Methods To collect electronic department of orthopedics 160 nursing records by using purposive sampling method, Extraction of vocabulary and nursing concept, words and terms which were not consistent with the field of medicine and nursing were performed and compared with the Chinese version of ICNP2.0. Results A total of 509 nursing records were extracted and classified according to 3 categories and 7 axes in ICNP 2.0. The distribution of the different types of words was nursing phenomena (accounting for 86.6%), nursing action (accounting for 11%) and nursing outcomes (accounting for 24%). The results of comparison between the clinical nursing records and the Chinese version of ICNP2.0 were completely matched (accounting to 28.1%) and partial matching (accounting for 393%). Conclusion Comparison resulting list of nursing terms between nursing records and ICNP version 2.0 can be structured for the formation of nursing language, and the realization of nursing records to provide reference for standardized writing. It is also conducive to the preservation and utilization of nursing information data, for the development of intelligent decision support system for clinical care.

[学科分类] 护理学

[关键词] 护理记录;国际护理实践分类;结构化分析