| Objective: In order to select the most appropriate standardized nursing terminologies for clinical application in hospitals,a systematic evaluation of the applicability and application effects of four standardized nursing terminologies—NANDA-NIC-NOC,Clinical Nursing Classification System(CCC),International Classification of Nursing Practice(ICNP),and Omaha System(OS)—in electronic health records was conducted.Methods: Computer and manual retrieval of Pub Med,Embase,Web of Science,CINAHL,CNKI,Wanfang and VIP databases will be conducted until November 2022.Literature screening,quality evaluation,data extraction and analysis were conducted independently by two researchers according to inclusion and exclusion criteria.Due to the different evaluation dimensions of outcome indicators,the study is divided into two parts: the applicability of standardized nursing language and the application effect of standardized nursing language.Results: In the systematic evaluation of the applicability of standardized nursing language,a total of 17 literature were included,all of which were descriptive studies.Among them,there are 8 studies on ICNP,5 studies on CCC,3 studies on OS and 1 study on NNN.The results showed that the matching degree of ICNP and nursing records was between 28.1%-87%,that of CCC and ICU,orthopedics and cardiology nursing records was above 74%,that of OS and perioperative and emergency patient nursing records after tumor surgery was between81-83%,and that of NNN and nursing records was above 80%.A total of11 literature were included in the systematic evaluation of the application of standardized nursing language in nursing electronic medical records,including 2 randomized controlled studies,6 quasi-experimental studies and 3 descriptive studies.Ten studies reported the effect of standardized nursing language on the quality of nursing records in nursing electronic medical records,including 6 studies on NNN,2 studies on CCC and 1study on ICNP.1 study comparing the application effect of NNN and ICNP.The results showed that the quality score and completeness of nursing records based on NNN and CCC were higher than before,while the accuracy of nursing records based on ICNP was lower than that of NNN.Two studies reported the impact on the efficiency of nursing record writing,showing that the use of NNN and CCC based nursing electronic medical record writing time was reduced.Conclusion: In general hospitals,the application of NNN is better,but the advantage of clinical applicability is not obvious.CCC has good clinical applicability and can have a positive impact on the quality and writing efficiency of nursing records after application,but relevant domestic studies are limited to ICU,orthopedics,cardiology and other specialties.More high-quality research is needed in the future to determine the most appropriate standardized language of care in specific clinical practice settings. |
