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KMID : 1164520120300010060
Journal of Military Nursing Research
2012 Volume.30 No. 1 p.60 ~ p.76
Development of Standard Nursing Statements to Establish an Electronic Nursing Record System in Wards of the Military Hospitals
Park Im-Hee

Choi Ji-Ahn
Han Ja-Kyoung
Keum Kyeong-Lim
Sim Hyun-Ok
Lee Young-Seon
Jung Jae-Eun
Choi Hyo-Seon
Kim You-Jin
Jung Eun-Young
Park Kyu-Eun
Song Mi-Ae
Shin Bo-Ra
Abstract
Purpose: The purposes of this study were to analyze narrative nursing statements retrieved in a military hospital based on the ICNP(International Classification of Nursing Practice) system to develop the standard nursing statements, and to serve as a foundation for establishing an electronic nursing record system.

Method : Narrative nursing statements were retrieved in medical/surgical wards of a military hospital, and nursing phenomena, nursing action and other nursing statements were extracted and refined. Mapping statements with ICNP concepts and integration of statements were conducted. Content validity of Statements was examined by experts. Based on how well the ICNP system can explain a statement, statements were categorized into full, partial and non description classes, and frequency of each was investigated. Frequency & Percentage of the ICNP axes and concepts were examined.

Results : From 56,193 statements, 2,236 standard nursing statements were extracted. Nursing phenomena statements took a larger portion than nursing action statements. Most of the statements were explained by the ICNP. Nursing statements used only 19.1% of ICNP concepts, indicating nursing officers document similar expressions. Military-specific concepts such as sick-leave were discovered.

Conclusion : The standard nursing statements are the foundation for a new electronic nursing record system promising quality care.
KEYWORD
computerized nursing record system, military nursing, international classification of nursing practice
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