中国全科医学Issue(23)：2680-2683,4.DOI:10.3969/j.issn.1007-9572.2014.23.004
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
摘要
Abstract
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 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.关键词
精神病/社区随访/护理记录/国际护理实践分类/结构化分析/对比研究Key words
Psychotic disorders/Community follow -up/Nursing records/International classification of nursing practice/Structured analysis/Comparative study分类
医药卫生引用本文复制引用
臧爽,李小寒,赵海平,臧渝梨,高艳萍,赵映红,陈瑜,赵梅珍..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[J].中国全科医学,2014,(23):2680-2683,4.基金项目
2012年度CMB护理青年教师科研基金项目 （）
