The purpose of this study was to seek the approach structuring the descriptive nursing documents and using the terminology as controlled vocabulary in electronic nursing record through the analysis of contents recorded in paper-based nursing documentation forms with the International Classification for Nursing Practice(ICNP).Sixty three patients nursing records, corresponding to documents of 395 days of a teaching Hospital in Seoul were used. From the chart review of the 5 nursing record forms; Nurses note, Delivery Floor Nursing Record I, II, Nursing History Record(Maternity), Nursing Discharge Plan(Maternity), narrative data and formatted data were collected and analyzed separately. Narrative data were broke down semantically into single sentences and classified according to the semantics. Formatted data were summarized by concepts from the nursing forms items. Fourteen thousand seven hundred twenty-seven statements and sixty-three items were analyzed. In the process of decomposing the narrative data into single statements, a constant pattern of contents like the nursing process and some contextual information, such as the other health professions behaviors or plans which were not classified in nursing phenomena or actions, were found. The 14,727 statements were represented into 237 unique statements and decomposed into 259 unique concepts. Among those 39.8%(103) were identified as local vocabulary, which represents the concrete concepts in detail in the maternity nursing field. In the analysis of 48 formatted items, 23(47.9%) concepts were local vocabulary. These study findings implied the effective method of structuring the narrative nursing documents and supported the importance of identifying the local vocabulary in terminology of ICNP based approach to improve and complement the expressiveness of clinical practice in detail enough.
KCI
