Evaluation of the expressiveness of ICNP terminology in a computerized nursing record system

초록

eHealth initiatives and urgency of EHR make vocabulary to be urgent issue for nursing. Yet uncoordinated vocabulary initiatives have prevailed and there was no convergence toward a unified nursing language system that is integrated within the larger health care language. The purpose of this paper is to evaluate the domain completeness and expressiveness issues of ICNP through the analysis of nursing notes of enterprise EMR system, in which ICNP was applied at constructing of coded nursing data dictionary (NDD) as a standard vocabulary, of one tertiary hospital in Korea. Data from more than 2,262 inpatients over a period of 9 weeks (May ~ July 2003) were extracted from the EMR system for analysis. Among the total data input (530,218 input events), the data of 75.7 % (401,190) were entered from the NDD and 3.9 % (10,543) were the only free text input, not used coded data. The other 20.5 % (108,478) were the combination of coded data and free text. Content analysis about the free text events showed that the expressions of 80.3 % could be found in NDD, 10.9 % were used for citation of patient complaints and responses, reference the care plan or orders of physicians, and etc. Seven point eight percent expressions were used for supplementary purpose such as adding a conjunction or end verb to make an expression smoothed. Only 1.0 % was identified not to be covered by NDD. Our evaluation study demonstrates that the ICNP have the enough expression power to cover the necessary expression of a clinical nursing setting.