Classification of nursing statements based on the ICNP, the HHCC, and the nursing process for use in electronic nursing records

Stud Health Technol Inform. 2006:122:718-21.

Abstract

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.

MeSH terms

  • Humans
  • Korea
  • Medical Records Systems, Computerized*
  • Nursing Care / classification*
  • Terminology as Topic*