간호과정 용어체계를 이용한 간호기록 분석 -군병원 정형외과 재원환자 기록 대상으로-

Purpose: This study was to construct a useful nursing language system on military nursing field. Method: Military hospital nursing records were analyzed using NANDA(North American Nursing Diagnosis Association), NIC(Nursing Interventions Classification), and NOC(Nursing Outcomes Classification) systems. All kinds of nursing statements from 80 sets of orthopedics inpatient`s records were deduced. All nursing statements were mapped to 167 NANDA diagnoses, 433 NIC interventions, and 260 NOC outcomes. Result: 14,744 nursing statements were extracted. Among the extracted nursing statements, 11.75% were linked with NANDA diagnosis, 83.62% were connected with NIC intervention, and 0.96% was tied to NOC outcome. 3.66% of nursing statements were not linked with NANDA-NIC-NOC system. In the nursing statements, 18 diagnoses of NANDA, 63 interventions of NIC, 8 outcomes of NOC were used. Conclusions: The majority of those nursing statements focused on nursing intervention of the nursing process; few nursing plans or goals were found in nursing records. Therefore, it`s difficult to make the nursing process network with the nursing statements. Documenting nursing records using a nursing process will contribute to strengthen nursing practice in patient care and to develop nursing as science. Continuous further researches related to nursing records are needed to provide basic data for developing nursing language system and nursing record system.