Burkhart Lisa, Androwich Ida
Marcella Niehoff School of Nursing, Loyola University Chicago, IL 60626, USA.
Comput Inform Nurs. 2004 Mar-Apr;22(2):72-82. doi: 10.1097/00024665-200403000-00007.
As the healthcare industry moves toward automating the patient record, care providers have been challenged to capture their domain of practice in a computerized format. Nurses have responded by developing a number of American Nurses Association (ANA) recognized nursing standardized terminologies. This study measured the domain completeness and uses of one such terminology, the Nursing Interventions Classification (NIC), within the specialty of parish nursing, a spiritually focused, community-based practice. Documentation samples from 170 health records submitted by 13 parish nurses in 7 sites across the country, stratified by urban, suburban, and rural sites were used. The nursing interventions that were documented in 1607 unique interactions in these charts were mapped into NIC using standardized mapping procedures. Intercoder reliability was assessed, with a final kappa of 0.92 (93% agreement) and code-recode reliability with a kappa of 0.72 (74% agreement). Overall, 93% of the 3059 interventions mapped into NIC. Recommended modifications in existing NIC labels and additional NIC labels are presented. The results suggest that NIC supports the documentation of parish nursing practice and has the capability of capturing the spiritual dimension of care.
随着医疗行业朝着患者记录自动化发展，医疗服务提供者面临着以计算机化格式记录其执业领域的挑战。护士们通过开发一些美国护士协会（ANA）认可的护理标准化术语做出了回应。本研究测量了一种此类术语——护理干预分类（NIC）在教区护理专业（一种以精神为重点、基于社区的实践）中的领域完整性和使用情况。使用了来自全国7个地点的13名教区护士提交的170份健康记录中的文档样本，并按城市、郊区和农村地点进行分层。这些图表中1607次独特互动中记录的护理干预通过标准化映射程序映射到NIC中。评估了编码员间信度，最终kappa值为0.92（一致性为93%），编码-重新编码信度kappa值为0.72（一致性为74%）。总体而言，3059项干预中有93%映射到了NIC中。文中提出了对现有NIC标签的建议修改以及额外的NIC标签。结果表明，NIC支持教区护理实践的记录，并且有能力捕捉护理的精神层面。
