Developing hierarchical standardized home care nursing statements using nursing standard terminologies

Area of Science:

• Nursing Informatics
• Health Information Management
• Clinical Documentation

Background:

• High-quality documentation is crucial for effective communication in home care nursing.
• Current home care nursing documentation often suffers from incompleteness and inaccuracies.
• Standardization is needed to improve the reliability of nursing records.

Purpose of the Study:

• To develop a hierarchical standardized home care nursing statement (S-HCNS) structure.
• To enhance the quality and completeness of home care nursing documentation.
• To leverage existing nursing terminology standards for improved data representation.

Main Methods:

• Collected one year of home care nursing notes from a South Korean agency.
• Utilized the International Classification for Nursing Practice (ICNP) and Clinical Care Classification (CCC) terminology standards.
• Mapped nursing notes to ICNP and classified S-HCNSs within the CCC to build a hierarchical structure.

Main Results:

• 1,230 S-HCNSs were derived from 61,061 nursing notes.
• 82.8% of statements were completely mapped to ICNP, with only 0.3% unmapped.
• 99.2% of S-HCNSs were classified within the CCC system, forming a hierarchical structure.

Conclusions:

• The ICNP and CCC demonstrated high mapping rates for creating the S-HCNS structure.
• Differences in granularity between ICNP and CCC facilitated a hierarchical representation of clinical details.
• The developed S-HCNS structure is expected to significantly improve home care nursing documentation quality and completeness.