精神病患者社区护理随访记录的结构化分析及其与国际护理实践分类的对比研究

Community Nursing Follow-up Records of Psychopaths:A Structured Analysis and Comparison with International Classification of Nursing Practice

目的分析精神病患者社区护理随访记录的结构及术语使用情况,并将其与国际护理实践分类2.0版本(ICNP2.0)进行对比,探讨实现我国社区护理记录结构化与标准化的可行性。方法采用整群抽样法,于2013年8月选择辽宁省沈阳市、大连市、朝阳市3个市,每个市抽取3家社区卫生服务中心,纳入9家社区服务中心治疗管理的所有已有电子健康档案的精神病患者,共计1 038例,排除健康档案不完整或无随访记录者。对所有精神病患者的护理随访记录进行分析。提取护理记录中的词汇,建立编码册,并与ICNP2.0中文版本进行对比。结果共提取458条词汇,按照INCP2.0的3个领域及7个轴向进行分类,护理现象领域包含的词汇量最多,为348条(76.0%);护理结局领域所包含的词汇量最少,仅为17条(3.7%)。焦点轴词汇在3个领域中所占的比例最大,为224条(48.9%);服务对象轴词汇在3个领域中所占的比例最小,为14条(3.0%)。社区精神病患者护理随访记录和ICNP2.0中文版完全匹配的词汇占29.2%(134/458),部分匹配的词汇占40.0%(183/458),无法匹配的词汇占30.8%(141/458)。部分匹配的词汇主要包括两类:第一类,意义相似,但表述不同的有12.4%(57/458);第二类,需要输入一些文字进行改动后才能与ICNP2.0中相应的词汇匹配的有27.5%(126/458)。精神病患者社区护理随访记录3个领域的词汇在与ICNP2.0版本的3个匹配程度等级上的分布情况,差异无统计学意义(χ2=6.20,P=0.185)。结论精神病患者社区护理随访记录与ICNP2.0对比所得到的术语列表可以为形成我国结构化的护理语言体系及促进社区护理记录规范化的书写提供参考。护士的书写习惯、语言文化和构词的差异性是将ICNP我国本土化推广时需要克服的重要问题。

Objective To analyze the structures and technical terms of nursing follow-up records of community psy-chopaths and compare with version 2. 0 of the International Classification of Nursing Practice（ ICNP ？ 2. 0 ）,to explore the pos-sibility of community nursing records structuralization and standardization in China. Methods Cluster sampling method was used to choose 1038 psychopaths who had electronic health records from 3 community health service centers in Shenyang,Dalian, Chaoyang in August 2013. The patients with or without incomplete health records were excluded. We analyzed all nursing follow-up records and extracted words in them to make coding books and then compared with ICNP ？ 2. 0 in Chinese version. ResUlts The 458 extracted terms were classified,according to 3 categories and 7 shafts of ICNP ？ 2. 0. The terms of nursing phenome-na category were the most（348 words,76. 0%）,those of nursing outcome category were the fewest（only 17 words,3. 7%）. Focus shaft terms accounted for the greatest proportion（ 224 words,48. 9%）;those of service object shaft accounted for the smallest proportion in 3 categories（14 words,3. 0%）. The words in the nursing follow-up records completely matching those＆amp;nbsp;in ICNP ？ 2. 0 accounted for 29. 2% （ 134/458 ）, those partly matching for 40. 0%（ 183/458 ）, those not matching for 30. 8%（141/458）. The partly matching words including 2 types：（1）words having similar meaning but expressed differently （12. 4%,57/458）;（2）words which matched those in ICNP ？ 2. 0 after changes of some words（27. 5%,126/458）. There was no significant difference in distribution of nursing phenomenon,nursing action and nursing outcome（χ2 =6. 20,P =0. 185 ）. ConclUsion The technical term list acquired by comparing nursing follow-up records with ICNP ？ 2. 0 can provide a basis for formation of structured nursing language system and promotion of the standardization of community nursing record writing in China. The diversity of nursesˊwriting habits,language culture and morphology is a major problem needed to be overcome in ICNP ？ localization and promotion.