Cross-mapping ICNP terms with Taiwanese gynecological nursing records

Cross-mapping the terms of International Classification for Nursing Practice (ICNP) with the handwritten nursing records of gynecological patients at one district of private teaching hospital in the south of Taiwan was conducted in July and August, 2004. The purpose of this study was to validate the applicability of ICNP for electronic nursing records in a gynecological setting. A Chinese version of the ICNP beta 2 browser was used to code nursing record sentences. Medical charts were reviewed until data were saturated. A total of sixty-two patient records were analyzed, producing 6,327 sentences, this included 1,918 sentences on nursing phenomena (30.3%) and 4,409 sentences on nursing action (69.7%). The ratio between the two was about 1:2.3. Coded sentences were compared according to the four levels of applicability with the original records, each was identified as a "perfect fit", "conceptual fit", "partial fit", or "unable to fit". Of the 6,327 sentences, 2,041 (32.3%) were designated as "perfect fit", 2,457 (38.8%) as "conceptual fit", 1,663 (26.3%) as "partial fit", and 166 (2.6%) as "unable to fit". The top ten most described nursing phenomena included: acute pain, high temperature, conscious change, potential infection risk, state of mind change, potential risk patient's mobility change endurance level, gastrointestinal function obstacles, changes in urination, anxiety, and diarrhea. The top ten most described nursing actions included: observe surgical wounds, monitor vital signs, changes of mentality, instruction on medication, arranging clinical check ups, wound infection prevention, urinary drainage tube and urine nature observation, checking for vaginal drainage, pre/post-operative healthcare, and discharge planning. Study results indicated that 71.1% of sentences could be cross-mapped. Further validation is suggested to validate ICNP in other gynecological hospitals.