Application Of Clinical Care Classification System In Icu Electronic Nursing Records

Objective1.To explore the applicability of Clinical Care Classification System(Chinese version 2.5)in ICU electronic nursing records,and to provide theoretical basis for the construction of structured electronic nursing records system based on Clinical Care Classification System.2.To design and develop a structured electronic nursing record system based on Clinical Care Classification System(Chinese version 2.5)and apply it to ICU,evaluate its application value,and provide empirical reference for promoting the construction of Standardized Nursing Terminologies.Methods1.Delphi expert consultation method was used to evaluate the applicability of nursing diagnosis and nursing interventions of Clinical Care Classification System(Chinese version 2.5)in ICU nursing records.2.Design and develop a structured electronic nursing record system based on Clinical Care Classification System(Chinese version 2.5),and apply it in ICU.The application effect was evaluated by the success rate of Standardized Nursing Terms selection,writing time,extraction frequency and rate of Standardized Nursing Terminologies.Results1.The recovery rate and effective rate of the two rounds of questionnaires were 100%,showing that Coefficient of expert authority,Coefficient of judgment basis,Coefficient of familiarity is 0.86,0.92,0.81 respectively.Two rounds of questionnaires shows that the coordination coefficient of nursing diagnosis is 0.254 and 0.141 respectively and coordination coefficient of nursing measure is 0.234 and 0.158 respectively.The applicability of Chinese version 2.5 of Clinical Care Classification System in ICU nursing records was 86.36%,152 of 176 nursing diagnoses were applicable,accounting for 94.03%,and 189 of 201 nursing interventions were applicable.2.Based on the CCC(Chinese version 2.5),the CCC structured electronic nursing record system in ICU was consists of six parts: user management module,department management module,knowledge base management module,patient management module,structured writing module,and statistical analysis module.The system was applied comprehensively in the ICU of a First-class Hospital in Chongqing.Nineteen nurses have documented nursing records of 174 ICU patients,and a total of 12495 standardized terms were used for nursing records.89.43%of Nurses have successfully found the required Standardized Nursing Terminologies.As the nurse’s experience increases,the average time for document input had significantly reduced from 170.5 seconds to 95.5seconds.The data extracted from the system shows that The high frequency of term of nursing interventions were: blood sample collection/test(2.38%),pulse monitoring(2.34%),catheter care(2.18%),posture change care(2.14%),body temperature monitoring(2.06%),vital signs monitoring(1.98%),bed rest care(1.93%),skin care(1.93%),blood pressure monitoring(1.89%),oral care(1.85%),breathing monitoring(1.73%),Venous catheter nursing(1.73%)which was consistent with the nursing work of ICU patients the characteristics of ICU patients and standard ICU nursing interventions.Meanwhile,The high frequency of term of nursing diagnosis were: skin integrity damage risk(3.21%),micturition change(2.97%),malnutrition risk(2.81%),comfort change(2.55%),activity intolerance(2.55%),physical activity dysfunction(2.45%),lack of knowledge(2.43%),anxiety(2.32%),lack of self-care ability(2.20%)Respiratory clearance dysfunction(2.14)which was consistent with the characteristics of ICU patients and standard ICU nursing diagnosis.Conclusion1 The application of Clinical Care Classification System(Chinese version 2.5)in ICU nursing records has good applicability and feasibility.2.The structured electronic nursing record system based on Clinical Care Classification system(Chinese version 2.5)has been designed and developed.It has been proved by clinical practice in ICU that it can reflect the characteristics of ICU nursing work and patients’ condition,improve the efficiency and quality of ICU nursing record,realize the sharing of clinical nursing data and standardized nursing information expression,and facilitate the statistical analysis of nursing terms,It is worth popularizing.