中国实用护理杂志
中國實用護理雜誌
중국실용호리잡지
CHINESE JOURNAL OF PRACTICAL NURSING
2014年
3期
1-4
,共4页
臧爽%李小寒%臧渝梨%王健
臧爽%李小寒%臧渝梨%王健
장상%리소한%장투리%왕건
社区%儿童保健%护理记录%国际护理实践分类%结构化分析
社區%兒童保健%護理記錄%國際護理實踐分類%結構化分析
사구%인동보건%호리기록%국제호리실천분류%결구화분석
Community%Child health care%Nursing records%International classification of nursing practice%Structured analysis
目的 分析社区儿童保健记录的语言结构及术语使用情况,探讨借鉴国际护理实践分类2.0版本(ICNP(R)2.0)实现社区护理记录结构化与标准化的可行性.方法 采用便利抽样法,收集432份来自辽宁省三家社区卫生服务中心的儿童保健手册,逐句分析护理记录,提取词汇,建立编码册,并与ICNP(R)2.0中文版本进行比照.结果 共提取567条社区儿童保健护理记录词汇,可归为护理现象、护理行动和护理结局3个类别及7个轴向,社区儿童保健记录无法完全符合国际护士会对于护理记录书写的分轴要求.社区儿童保健记录中有146条词语在表述上和ICNP(R)2.0中的词语达到完全一致,223条词汇与ICNP(R) 2.0不匹配.护理现象、护理行动和护理结局在各等级适用性分布的差异具有统计学意义.能够适配及无法适配的词语护理行动所占的比例大,无法适配的词语护理现象和护理结局所占的比例高.结论 我国社区护理记录与ICNP(R)2.0存在一定的差异,社区儿童保健护理记录与ICNP(R) 2.0比照所得到的术语列表可以为形成结构化的护理语言系统及完善我国的社区护理记录语言奠定基础.
目的 分析社區兒童保健記錄的語言結構及術語使用情況,探討藉鑒國際護理實踐分類2.0版本(ICNP(R)2.0)實現社區護理記錄結構化與標準化的可行性.方法 採用便利抽樣法,收集432份來自遼寧省三傢社區衛生服務中心的兒童保健手冊,逐句分析護理記錄,提取詞彙,建立編碼冊,併與ICNP(R)2.0中文版本進行比照.結果 共提取567條社區兒童保健護理記錄詞彙,可歸為護理現象、護理行動和護理結跼3箇類彆及7箇軸嚮,社區兒童保健記錄無法完全符閤國際護士會對于護理記錄書寫的分軸要求.社區兒童保健記錄中有146條詞語在錶述上和ICNP(R)2.0中的詞語達到完全一緻,223條詞彙與ICNP(R) 2.0不匹配.護理現象、護理行動和護理結跼在各等級適用性分佈的差異具有統計學意義.能夠適配及無法適配的詞語護理行動所佔的比例大,無法適配的詞語護理現象和護理結跼所佔的比例高.結論 我國社區護理記錄與ICNP(R)2.0存在一定的差異,社區兒童保健護理記錄與ICNP(R) 2.0比照所得到的術語列錶可以為形成結構化的護理語言繫統及完善我國的社區護理記錄語言奠定基礎.
목적 분석사구인동보건기록적어언결구급술어사용정황,탐토차감국제호리실천분류2.0판본(ICNP(R)2.0)실현사구호리기록결구화여표준화적가행성.방법 채용편리추양법,수집432빈래자요녕성삼가사구위생복무중심적인동보건수책,축구분석호리기록,제취사회,건립편마책,병여ICNP(R)2.0중문판본진행비조.결과 공제취567조사구인동보건호리기록사회,가귀위호리현상、호리행동화호리결국3개유별급7개축향,사구인동보건기록무법완전부합국제호사회대우호리기록서사적분축요구.사구인동보건기록중유146조사어재표술상화ICNP(R)2.0중적사어체도완전일치,223조사회여ICNP(R) 2.0불필배.호리현상、호리행동화호리결국재각등급괄용성분포적차이구유통계학의의.능구괄배급무법괄배적사어호리행동소점적비례대,무법괄배적사어호리현상화호리결국소점적비례고.결론 아국사구호리기록여ICNP(R)2.0존재일정적차이,사구인동보건호리기록여ICNP(R) 2.0비조소득도적술어렬표가이위형성결구화적호리어언계통급완선아국적사구호리기록어언전정기출.
Objective To analyze the language structure of nursing records and the application of defined vocabulary in nursing records of community child care,and to explore the possibility of structuralization and standardization of community nursing records by researchers' consulting International Classification of Nursing Practice (ICNP(R)2.0).Methods Convenient sampling method was used.A total of 432 handbooks about child health care were extracted from three community health service centers in Liaoning province.By analyzing the nursing records,the vocabulary was selected,and a coding book was built.Then researchers compared them with ICNP(R)2.0 Chinese version.Results Totally 567 terms were extracted.All phrases in nursing records about community child health care can be classified into three categories and seven shafts,which were nursing phenomenon,nursing action and nursing outcome.Our community nursing records about child health care could not fully meet shaft level of nursing record writing requirements from the International Council of nurses.Only 146 records were labeled as "perfect fit" with ICNP(R)2.0 terminology,223 records as "not fit at all".The difference of different levels of suitability distribution about nursing phenomenon,nursing action and nursing outcome had statistically significant difference.Words of able to adapt and can't adapt about nursing action had larger proportion.Words that can't adapt about nursing phenomenon and nursing outcome had larger proportion.Conclusions There is still certain gap between domestic nursing records and ICNP(R)2.0 terminology.The list of terms from comparison nursing records about community child health care with ICNP(R)2.0 can lay the foundation for nursing language system structure and perfect community nursing record language in our country.
