Comparing nursing terms from patient records to the ICNP, beta version

Area of Science:

• Nursing Informatics
• Clinical Documentation Standards
• Healthcare Terminology

Background:

• Accurate patient care documentation is essential for continuity of care and evaluating outcomes.
• The increasing use of computers in healthcare necessitates standardized documentation practices.
• Existing clinical vocabularies often fall short in supporting comprehensive clinical documentation.

Purpose of the Study:

• To investigate the specific words used in documenting inpatient clinical assessments.
• To evaluate the coverage of these terms within the International Classification for Nursing Practice (ICNP).

Main Methods:

• A selection of 761 words commonly used in inpatient clinical assessment documentation was identified.
• These selected words were systematically mapped to the International Classification for Nursing Practice (ICNP).

Main Results:

• Only 247 out of the 761 investigated words were found to be included in the ICNP.
• This indicates a significant gap in the current nursing classification system's ability to encompass everyday clinical documentation terms.

Conclusions:

• The International Classification for Nursing Practice (ICNP) requires enhancement to better reflect the language used in clinical practice.
• Improvements in standard terminologies are necessary to facilitate better clinical documentation and, consequently, patient care quality.