Analysis of electronic nursing records based on the ICNP

Area of Science:

• Nursing Informatics
• Health Information Systems
• Clinical Terminology

Background:

• Traditional paper-based nursing records present challenges in standardization and data analysis.
• The International Classification for Nursing Practice (ICNP) offers a standardized terminology for nursing.
• Developing electronic systems is crucial for modernizing healthcare documentation.

Purpose of the Study:

• To analyze paper-based narrative nursing records using the ICNP.
• To evaluate the practical application of the ICNP and the developed Electronic Nursing Record (ENR) system for surgical patients.
• To identify areas for improvement in nursing terminology and electronic record systems.

Main Methods:

• Analysis of paper-based narrative nursing records from surgical patients.
• Application of the International Classification for Nursing Practice (ICNP) terminology.
• Development and implementation of the ENR System at Seoul National University Bundang Hospital.
• Evaluation of the system's practical usability.

Main Results:

• The ENR System was successfully built and applied to surgical patient records.
• Analysis using ICNP provided insights into the expressiveness of nursing records.
• A significant need was identified to add new concepts to the ICNP.
• Improvements are particularly required for describing nursing actions.

Conclusions:

• The ENR System, utilizing ICNP, demonstrates potential for enhancing nursing record documentation.
• The ICNP requires further development, specifically in incorporating new concepts for nursing actions.
• Refining nursing terminologies is essential for improving the quality and detail of electronic nursing records.