西安市社区孕产妇保健记录的结构化分析及与国际护理实践分类的交叉比照研究

Structuralization analysis on community maternal health care records in Xi'an city and cross-comparison with ICNP

目的:探讨借鉴国际护理实践分类实现我国社区护理记录的结构化和标准化的可行性。方法:采用便利取样法收集893份来西安市社区卫生服务中心的孕产妇保健手册,应用内容分析法逐句分析护理记录,提取词汇,按照INCP的层级划分方式进行护理记录词汇结构分类并与INCP2.0中文版本进行比照。结果:共提取436条社区孕产妇保健护理记录词汇,可归为护理现象、护理行动和护理结局3个类别及7轴级,各类别词汇的分布比例是护理现象79.82%、护理行动16.74%、护理结局3.44%。焦点轴的词汇所占比例最大为59.63%,服务对象轴所占比例最小为1.61%。社区孕产妇保健记录和ICNP2.0中文版完全一致的词汇占19.73%,部分匹配的词汇占38.07%,无法匹配的词汇占42.20%。护理现象、护理行动和护理结局3个类别的词汇在与ICNP2.0版本的3个匹配程度上的分布差异有统计学意义(P<0.01)。结论:国际护理实践分类3个类别及7个轴级的划分具有促进我国社区护理记录结构化、标准化的作用。社区孕产妇保健记录与国际护理实践分类比照所得到的术语列表为我国社区护理记录的书写扩展了词汇,同时也可以为护理记录书写的规范化提供了参考。

Objective： To explore the feasibility of strueturalization and standardization of community nursing records based on International Classification of Nursing Practice （ICNP） . Methods： Convenient sampling method was used to collect 893 handbooks about maternal health care from the community health service center in Xi＇an city. Content analysis method was employed to analyze the nursing records ; the vocabulary was selected, and the researchers were compared with ICNP 2.0 Chinese version. Results ： Totally 436 terms were extracted. All phrases of nursing records about maternal community health care can be classified into three categories and seven shafts, which were consisted of nursing phenomenon （79. 82% ）, nursing action （16.74%）, and nursing outcome （3.44%） . The proportion of the focus shaft in vocabulary was the largest （59.63%） ; the proportion of the service object shaft was the smallest （1.61%） . The proportion of the community nursing records about maternal health care which were labeled as ＂perfect fit＂ with ICNP 2. 0 terminology was 19. 73% ; the proportion of the records which were labeled as ＂partially fit＂ was 38.07% ; and the proportion of the records which were labeled as ＂not fit at all＂ was 42. 20%. There were statistically significant differences in distributions of three categories in nursing phenomenon, nursing action, and nursing outcome between the vocabularies and ICNP 2. 0 （ P 〈 0.01 ） . Conclusion： The three classifications and seven shaft levels according to ICNP can promote structuralization and standardization of Chinese community nursing records. The terminology glossary obtained by the comparison between nursing records of community maternal health care and ICNP, which provides references for standardization of nursing records - written.