Objectives

Home care nursing requires high quality documentation to facilitate communication between health providers. Despite the awareness surrounding the importance of documentation, the home care nursing environment lends itself to incomplete and inaccurate documentation. Our study aims to develop a hierarchical standardized home care nursing statement (S-HCNS) structure that can increase documentation quality and completeness.

Methods

We collected a year of home care nursing notes from a hospital-based home care nursing agency in South Korea. Two nursing terminology standards, the International Classification for Nursing Practice (ICNP) and the Clinical Care Classification (CCC), were used to develop the hierarchical S-HCNS structure.

Results

A total of 1,230 S-HCNSs were derived by mapping 61,061 home care nursing notes to the ICNP. Among the total statements, 82.8 % were completely mapped and 0.3 % were not mapped. A total of 99.2 % of the S-HCNSs were classified within the CCC system to build a hierarchical S-HCNS structure.

Conclusions

The ICNP and CCC showed high mapping rates when building the hierarchical S-HCNSs. The unmapped concepts did not exist in the CCC or ICNP but existed in other terminology systems such as SNOMED CT. The differences in granularity between the two terminology standards enabled the development of a hierarchical structure, which enabled the representation of the appropriate level of detail found within clinical documentation. We expect this structure will increase documentation quality and completeness.

中文翻译：

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使用护理标准术语开发分层的标准化家庭护理护理声明。

目标

家庭护理需要高质量的文档，以促进医疗服务提供者之间的沟通。尽管人们意识到文件的重要性，但家庭护理环境仍然导致文件不完整和不准确。我们的研究旨在开发一种分层的标准化家庭护理护理声明（S-HCNS）结构，该结构可以提高文档质量和完整性。

方法

我们从韩国一家医院的家庭护理机构中收集了一年的家庭护理说明。两种护理术语标准，即国际护理实践分类（ICNP）和临床护理分类（CCC），用于开发分层的S-HCNS结构。

结果

通过将61,061个家庭护理护理记录映射到ICNP，总共获得了1,230个S-HCNS。在所有语句中，完整映射为82.8％，未映射为0.3％。在CCC系统中，总共99.2％的S-HCNS被分类以建立分层的S-HCNS结构。

结论

ICNP和CCC在构建分层S-HCNS时显示出较高的映射率。未映射的概念在CCC或ICNP中不存在，但在其他术语系统（例如SNOMED CT）中存在。两种术语标准之间粒度上的差异使得可以开发出层次结构，从而可以表示临床文档中合适的详细程度。我们希望这种结构将提高文档质量和完整性。