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

Applications and researches of international classification for nursing practice in structural analysis of nursing records in the Department of Orthopedics

目的探讨国际护理实践分类(ICNP)在骨科电子护理记录结构化中应用的可行性。方法采用立意取样法,收集骨科电子护理记录160份,提取其中词汇及护理概念,剔除与医学及护理领域不相符的词汇及术语,并与ICNP2.0中文版进行比照。结果共提取509条护理记录词汇,按照ICNP2.0中文版的3个类别、7个轴级进行分类;各类别词汇分布比例分别为护理现象86.6%、护理行动11.0%、护理结局2.4%;临床护理记录和ICNP2.0中文版词汇匹配程度比较结果分别为完全匹配28.1%、部分匹配39.3%。结论骨科护理记录与ICNP2.0比照所得到的护理术语列表可以为结构化护理语言的形成、实现护理记录标准化书写提供参考,也有利于护理信息资料的保存和利用,为下一步开发临床护理智能化决策支持系统做准备。

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 7axes 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. 0were 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. 0can 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.