J Korean Soc Med Inform.  2002 Sep;8(3):11-18.

Contents Analysis of Paper-Based Nursing Documents for Electronic Nursing Record Using ICNP

• Cho IS
• Park HA

Abstract

The purpose of this study was to seek the approach structuring the descriptive nursing documents and using the terminology as controlled vocabula ry in elec tronic nursing r ecord through the analysis of contents re corded in paper-based nursing documentation forms with the International Classification for Nursing Practice(ICNP). Sixty three patients'nursing re cords, corresponding to documents of 395 days of a teaching Hospital in Seoul were used. From the chart review of the 5 nursing record forms; Nurses'note, Deliver y Floor Nur sing Record I, II, Nur sing History Record(Mate rnity), Nur sing Discha rge Plan(Maternity), na rrative da ta and formatted data wer e collecte d and analyzed separately. Na rrative data were broke down semantically into single sentences and classified according to the semantics. Formatted data were summarized by concepts from the nursing forms'items. Fourteen thousand seven hundred twenty-seven statements and sixty-three items were analyzed. In the process of decomposing the narrative data into single statements, a constant pattern of contents like the nursing process and some contextual information, such as the other health professions'behaviors or plans which were not classified in nursing phenomena or actions, were found. The 14,727 statements were represented into 237 unique statements and decomposed into 259 unique concepts. Among those 39.8%(103) were identified as local vocabulary, which represents the concrete concepts in detail in the maternity nursing field. In the analysis of 48 formatted items, 23(47.9%) concepts were local vocabulary. These study findings implied the effective method of structuring the narrative nursing documents and supported the importance of identifying the local vocabulary in terminology of ICNP based approach to improve and complement the expressiveness of clinical practice in detail enough.

Keyword

Nursing Record; Medical Record Systems; Computerized; Terminology; Vocabulary; Controlled; ICNP(International Classification for Nursing Practice)