Classification of nursing statements based on the ICNP, the HHCC, and the nursing process for use in electronic nursing records.
The purposes of this study were to identify nursing-phenomena-related statements and nursing-action- related statements for use in nursing records, to link nursing statements for the nursing process, to develop integrated nursing terms using the ICNP, to identify new terms for inclusion, and to group statements using the HHCC in a user interface. We extracted 5,133 nursing-phenomena-related statements and 3,844 nursing-action-related statements, with the former including 233 nursing diagnoses. A total of 2791 nursing terms were mapped and 287 new terms were developed. Synonyms of 827 standard nursing terms were extracted. We developed trees of nursing statements using the HHCC for the user interface in an electronic nursing record. The quality of nursing documentation and the nursing performance improved with the standardization process.
Yu
Ok-Su
OS
Nursing Information Committee, Seoul National University Hospital, Seoul, Korea.
Park
Ihn-Sook
IS
Joo
Young-Hee
YH
Woo
Kyung-Sun
KS
Shin
Hyeon-Ju
HJ
Ahn
Tae-Sa
TS
Kim
Eun-Man
EM
Jung
Eun-Hee
EH
Kim
Young-Ah
YA
Oh
Pil-Joo
PJ
Park
Hyeoun-Ae
HA
Jo
Eun-Mi
EM
Baek
Hye-Jin
HJ
D006801:Humans; D007723:Korea; D016347:Medical Records Systems, Computerized; D009732:Nursing Care / Q000145:classification*; D009626:Terminology as Topic