Sir Run Run Shaw Hospital School of Medicine, Zhejiang University, Hangzhou, China.
Nurs Open. 2021 Sep;8(5):2686-2695. doi: 10.1002/nop2.825. Epub 2021 Mar 24.
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.
A multi-centre cross-sectional study.
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.
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).
分析神经状况护理评估术语的应用现状，并确定国际功能、残疾和健康分类（ICF）是否涵盖护理评估。
多中心横断面研究。
4 位研究人员从 3 家不同医院的患者中提取所有护理问题，并从电子护理记录、自我报告、家庭报告、医学检查和所有患者的临床记录中形成护理术语库。然后使用 ICF 链接规则将神经状况的护理评估术语与 ICF 进行映射。
尽管 37.5%的护理评估术语与神经疾病密切相关，但这并未出现在现有的电子护理评估记录中。未记录的术语有 9 项（16.1%），范围在 40%-50%之间，而未记录的术语有 8 项（14.3%）超过 80%。总体而言，96.4%的护理评估术语可以用 ICF 的相应类别来描述，其中 37 项（66.1%）为“相同”概念，9 项（16.1%）为“相似”概念，6 项（10.7%）为“更具体”概念（护理评估术语比 ICF 类别更具体），2 项（3.6%）为“更宽泛”概念（护理评估术语比 ICF 类别更不具体）。
