Aim: To analyse the application status of nursing assessment terminology for neurological conditions and determine whether the International Classification of Functioning, Disability, and Health (ICF) covers nursing assessment.
Design: A multi-centre cross-sectional study.
Methods: Four researchers extracted all nursing problems from the patients of three different hospitals and formed a pool of nursing terminology from the electronic nursing records, self-reports, family reports, medical examinations, and clinical records for all patients. The ICF Linking Rules were then used to map the nursing assessment terminology of neurological conditions with the ICF.
Results: Though 37.5% of nursing assessment terms were closely related to neurological diseases, this does not appear in the existing electronic nursing assessment records. The unrecorded rate of 9 (16.1%) terms ranged from 40%-50%, while the unrecorded rate of 8 (14.3%) terms was more than 80%. Overall, 96.4% of nursing assessment terms could be described by the corresponding categories of the ICF, with 37 (66.1%) of the "same" concepts, 9 (16.1%) "similar" concepts, 6 (10.7%) "narrower" concepts (the nursing assessment terms were more specific than the ICF categories), and 2 (3.6%) "broader" concepts (the nursing assessment were less specific than the ICF categories).
Keywords: neurological conditions; nursing informatics; terminology.
© 2021 The Authors. Nursing Open published by John Wiley & Sons Ltd.