| ObjectivesThis study was to analyze the attributes of nursing documents in wards in hospital, and to explore the possible standardization of data elements in these documents. It was anticipated to lay the foundation for development standardized nursing documentation system.Methods1 Nursing documents categorizationA two-stage participatory field study was conducted. Data were collected and analyzed from a convenience sample consisting of nursing documents from five third-class A level hospital in Shandong province.At the first stage, two researchers entered one of the five hospitals and worked as student nurse to collect nursing documents from six representative wards in this hospital and categorized them into different categories according to their function. The head nurse and 2-3 representative nurses in each ward were invited to discuss with the sufficiency of the collecting and the scientificity of the categorization, and the result would be revised according to the discussion.At the second stage, the researcher entered the other four hospitals and collected nursing documents from representative wards in each hospital. Make sure that every kind of nursing document collected from each ward can be categorized with the result of the first stage, and wether there was new kind of nursing document which was not in the categorization.2 Data elements extractionExtracted data element in a way of down-top, i.e. from the work process medium (nursing documents). Selected nursing documents which had the same or similar contents and also appeared three or more times, Categorized data items of the same type according to their semanteme, categorized and abridged, merged the repetitive items and deleted the items with low frequency, then abstracted, i.e. named the data items according to their innate character.3 Data elements standardizationRetrieved all related national standards and latest professional standards, categorized the data elements according to the extent about their attributes referring to these standards, categorized as'complete adoption','incomplete adoption'and'no adoption'.During the research, categorization of each stage confirmed by a researcher who is familiar with clinical nursing and nursing research and remain neutral to the research. The nomenclature and categorization had been under negotiation through debriefing. An expert majoring in nursing standards reviewed all items until an agreement was reached. The comparison research between the attributes of data elements and related standards was completed by a research student who had training experience in China National Institute of Standardization (CNIS) and Shandong Institute of Standardization (SDIS). There was discussion between the researcher and the collator to reach agreement Where there was some doubt.Results1 Nursing documents categorization. Inhospital nursing documents can be categorized into five categories according to their functional attributes.i.e. nursing record, nursing executive sheet, management record, mediate record and referral record.2 Data element and its attributes categorization in nursing document. Totally 915 data elements were extracted from nursing documents, after treating with the repetitive ones, there were 352 data elements extracted to be standardized which can be categorized into 13 thematic fields on the basis of their functional attributes, i.e. archive information, institution information, time information, personnel information, diagnosis and treatment, illness condition, implementation records, nursing delivery, materials management, drug management, human resources administration, quality control and infection control. Among the 352 data elements,143 belong to'complete adoption'type,51 belong to'incomplete adoption'type while 158 belong to'no adoption'type according to the standardization of their attributes. ConclusionElectronization, standardization and intellectualization of nursing document is the goal and demonstration of nursing practice development pass through informatization as well as the necessary guarantee for nursing high quality project being implemented. This study categorized and analyzed inhospital nursing documents through participatory field study method and extracted data elements to be standardized by way of down-top. The research found that nursing document and its data elements in hospital wards are complicated and diversified. Also the existing NDS desiderates normalization and standardization. However, the current national and occupation standards still can not satisfy the requirement of standardization on nursing documents'data elements and their attributes. Therefore, nursing information standardization including research, education and practice is the power and guarantee to realize standardization and intellectualization of NDS, NIS and other nursing information systems.
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