护理本科生应用临床照护分类系统分析护理记录单的实践研究

Application analysis on the use of Clinical Care Classification System for nursing undergraduates about medical records of Alzheimer's disease

目的分析护理本科生在阿尔茨海默病患者病历中应用临床照护分类系统(Clinical Care Classification System,CCC)的情况。方法2022年6月—12月,由2名护理学专业教师提前收集阿尔茨海默病患者病历并制订护理标准化术语作为参考答案,经预实验后以抽签形式为每名学生分配1份病历。选取2022级116名全日制护理专业本科生基于临床照护分类系统分析患者病历,并编码相关护理诊断、护理措施和护理结局。随后评价学生编码的正确率并统计编码错误的情况分布,对学生进行半结构式访谈了解其运用标准化术语的体验。结果116名学生对116份病历最终共编码分析9502条护理术语,包括1276条护理诊断,6950条护理措施,1276条护理结局;学生编码正确率最高为100%,正确率最低为58.82%,正确率均值为88.18%。学生术语编码错误主要集中在思维过程改变、脑部改变、伤害风险等护理诊断及活动、身体调节、安全等类别护理措施中。学生认为临床照护分类系统能体现护理程序的步骤及内容,并可涵盖大部分阿尔茨海默病患者照护行为;临床照护分类系统在阿尔茨海默病患者病历中的映射和分析存在一定困难,但理论及实践探索可促进对临床照护分类系统的学习及应用。结论护理本科生基本能够理解临床照护分类系统并在阿尔茨海默病患者病历分析中进行应用,建议在教学中增加相应内容,提高学生对临床照护分类系统的运用能力。

Objective To explore the application analysis on the use of clinical care classification system for nursing undergraduates about medical records of Alzheimer's disease.Methods Two teachers collected medical records and developed standardized terminology reference criteria in advance,after pre-experiments,medical records were distributed by drawing lots.Based on the clinical care classification,116 full-time nursing undergraduate students enrolled in 2022 analyzed the patient's medical records and coded relevant nursing diagnosis,nursing measures and nursing outcomes,the correct rate of coding and the error distribution of coding were counted.Meanwhile,semi-structured interview was conducted with students to understand their experience in using clinical care classification.Results A total of 9502 nursing terms were coded and analyzed by 116 students,including 1276 nursing diagnoses,6950 nursing measures,and 1276 nursing outcomes.The highest coding accuracy rate of students was 100%,the lowest correct rate was 58.82%,and the average correct rate was 88.18%.The coding errors in nursing diagnosis were mainly concentrated in thought processes alteration,cerebral alteration,injury risk,etc.,while the coding errors in nursing measures were mainly concentrated in categories of nursing measures such as activity,physical regulation and safety.Students believed that clinical care classification could reflect the steps and content of nursing procedures and could cover the care behavior of most Alzheimer's disease patients.There were certain difficulties in mapping and analyzing clinical care classification in the medical records,but theoretical and clinical exploration could promote the learning and application.Conclusion Undergraduate nursing students are generally able to understand and apply the clinical care classification system,analyze and apply it in the medical records of Alzheimer's disease patients.This study provides certain reference value for the teaching of standardized nursing terminology.