辽宁省社区儿童保健记录的结构化分析及其与国际护理实践分类的比照研究

Structuralization of Hospital Nursing Records of Community Child Health Care in LiaoningProvince and its cross-mapping with International Classification of Nursing Practice

目的分析社区儿童保健记录的语言结构及术语使用情况，探讨借鉴国际护理实践分类2．0版本（ICNPR2．0）实现社区护理记录结构化与标准化的可行性。方法采用便利抽样法，收集432份来自辽宁省三家社区卫生服务中心的儿童保健手册，逐句分析护理记录，提取词汇，建立编码册，并与ICNPR2．0中文版本进行比照。结果共提取567条社区儿童保健护理记录词汇，可归为护理现象、护理行动和护理结局3个类别及7个轴向，社区儿童保健记录无法完全符合国际护士会对于护理记录书写的分轴要求。社区儿童保健记录中有146条词语在表述上和ICNlCR2．0中的词语达到完全一致，223条词汇与ICNPR2．0不匹配。护理现象、护理行动和护理结局在各等级适用性分布的差异具有统计学意义。能够适配及无法适配的词语护理行动所占的比例大，无法适配的词语护理现象和护理结局所占的比例高。结论我国社区护理记录与ICNPR2．0存在一定的差异，社区儿童保健护理记录与ICNPR2．0比照所得到的术语列表可以为形成结构化的护理语言系统及完善我国的社区护理记录语言奠定基础。

Objective To analyze the language structure of nursing records and the application of defined vocabulary in nursing records of community child care, and to explore the possibility of structural- ization and standardization of community nursing records by researchers＂ consulting International Classifica- tion of Nursing Practice （ICNP^2.0）. Methods Convenient sampling method was used. A total of 432 handbooks about child health care were extracted from three community health service centers in Liaoning province. By analyzing the nursing records, the vocabulary was selected, and a coding book was built. Then researchers compared them with ICNP^2.0 Chinese version. Results Totally 567 terms were extracted. All phrases in nursing records about community child health care can be classified into three categories and seven shafts, which were nursing phenomenon, nursing action and nursing outcome. Our community nursing records about child health care could not fully meet shaft level of nursing record writing requirements from the International Council of nurses. Only 146 records were labeled as ＂perfect fit＂ with ICNPR2.0 terminol- ogy, 223 records as ＂not fit at all＂. The difference of different levels of suitability distribution about nursing phenomenon, nursing action and nursing outcome had statistically significant difference. Words of able to adapt and can＇t adapt about nursing action had larger proportion. Words that can＇t adapt about nursing phe- nomenon and nursing outcome had larger proportion. Conclusions There is still certain gap between do- mestic nursing records and ICNPR2.0 terminology. The list of terms from comparison nursing records about community child health care with ICNPR2.0 can lay the foundation for nursing language system structure and perfect community nursing record language in our country.