[AP1-E2-2-01] Development of Home-Visit Nursing Record Template Contents
NANDA-I (North American Nursing Diagnosis-International), NIC (Nursing Interventions Classification), NOC (Nursing Outcome Classification), Standard Terminology for Nursing Observation and Action, Template Contents
Home-visit nurse often write down their records in free format. It makes difficult to share information with community healthcare institutions and provide objective evaluation of nursing practice. In this study, we developed a home-visit nursing record template contents for obtaining structured data in standardized nursing terminology (SNT). We conducted a medical records review of 60 case of 46 inpatients at Osaka University Hospital who were shifted to home-visit nursing after discharge, and collected the observation items passed on to home-visit nurse. One hundred and twenty five types of observation items were listed from medical records of target patients. The observation items were subjected to cluster analysis to classify them into effective recording unit. According to the classification, we created following 7 templates: “Immobility consequences, Pressure ulcer prevention/care”, “Drug reaction”, “Need blood glucose control”, “Lung-related symptoms”, “Post-operative”, “Chemotherapy”, “Fall prevention”.