Nursing Department, Inha University, Incheon, Korea.
Asan Medical Center, Seoul, Korea.
Int Nurs Rev. 2020 Jun;67(2):239-248. doi: 10.1111/inr.12566. Epub 2019 Nov 24.
The International Council of Nurses supports the development of International Classification for Nursing Practice® (ICNP®) catalogues to support the construction of electronic health records and evidence-based practice. Such a catalogue is needed for inpatient falls.
The ICNP®-Based Inpatient Fall-Prevention Catalogue ('The Catalogue') was developed following the six steps recommended by the International Council of Nurses: (1) identifying inpatient falls as a priority, (2) gathering relevant concepts from 10 international guidelines and comparing locally defined sets of fall-prevention terms, (3) mapping the concepts to the ICNP® terminology, (4) identifying new concepts, (5) conducting a clinical face validation with a 12-member panel and finalizing The Catalogue and (6) setting a strategy for dissemination. The high-level structure of the International Classification for Patient Safety was used as a theoretical framework.
Eighteen nursing care elements and 141 terms were identified. A local vocabulary set had 89 terms (63.1%) that all corresponded to the identified terms. The exact and post-coordination mapping rates to the ICNP® were 75% and 40.6% for assessment/diagnosis/outcomes and interventions, respectively. The 54 new terms corresponded to 52 primitive concepts. An external review of The Catalogue showed that it had adequate understandability and validity. However, one-third of assessments/diagnoses/outcomes and one-fourth of interventions were not found in a tertiary hospital practice.
A fall-prevention catalogue has been developed based on evidence and a theoretical framework and also clinically validated.
The Catalogue is a standardized interface terminology and content subset in any electronic health records system that can directly deliver evidence on fall prevention. It can also be used as an informatics tool to aggregate, analyse, interpret and compare nursing data worldwide.
国际护士理事会支持开发国际护理实践分类（ICNP®）目录，以支持电子健康记录和循证实践的构建。住院患者跌倒需要这样一个目录。
遵循国际护士理事会推荐的六个步骤开发了 ICNP®基于住院患者跌倒预防目录（“目录”）：（1）确定住院患者跌倒为优先事项，（2）从 10 项国际指南中收集相关概念，并比较当地定义的跌倒预防术语集，（3）将概念映射到 ICNP®术语，（4）确定新的概念，（5）与 12 人小组进行临床面对面验证，并最终确定目录，（6）制定传播策略。国际患者安全分类的高级结构被用作理论框架。
确定了 18 个护理护理要素和 141 个术语。当地词汇集有 89 个术语（63.1%）与确定的术语完全对应。评估/诊断/结果和干预措施的精确和后置协调映射率分别为 ICNP®的 75%和 40.6%。54 个新术语对应 52 个原始概念。对目录的外部审查表明它具有足够的可理解性和有效性。然而，三分之一的评估/诊断/结果和四分之一的干预措施在一家三级医院的实践中并未发现。
基于证据和理论框架，以及临床验证，已经开发了预防跌倒的目录。
目录是任何电子健康记录系统中的标准化接口术语和内容子集，可以直接提供预防跌倒的证据。它还可以用作信息学工具，用于汇总、分析、解释和比较全球护理数据。
