Abstract：Objective To discover the status of structured nursing diagnosis in the PIO nursing records of inpatients.Methods In this study,objective sampling method was used.In June 2017,131 inpatients discharged from 22 specialties in 2 secondary and tertiary comprehensive medical institutions in Shanghai were collected.Nursing information team members extracted and counted the nursing diagnosis and frequency in nursing records,and compared with the principles of nursing diagnosis terms in International Classification of Nursing Practice (ICNP).Results A total of 121 nursing diagnosis were extracted,of which frequency ranging from 1 to 73.Total frequency was 897 times and 81(66.94%) of them met the principle of composition in ICNP.Conclusion Nursing diagnosis structure is a part of nursing terminology standardization,which is directly related to the collection of nursing indicators and the sharing of information.Nursing managers should pay more attention to the construction of nursing informatization in medical institutions.
京公网安备 11010502046607号