Analyzing nursing notes by cross-mapping to ICNP(International

Classification for Nursing Practice) in maternity unit of one of the tertiary

hospitals in Pakistan
Jungyun Hong, RN, MSN, Rafat J. Ruknuddin, RN, PhD
Aga Khan University, School of Nursing, Karachi, Pakistan
Abstract
The purpose of this study was to cross-mapped maternity nursing records with ICNP 2.0. Narrative nursing notes
were collected from 25 inpatients records which were decomposed and unified into single sentence and classified as
nursing phenomena, nursing intervention and contextual information. The total numbers of nursing statements were
4,263 and the redundancy rate was 10.3 times. 219 (61.3%) statements were cross-mapped completely, 137 (38.4%)
statements were mapped partially and only one (0.3%) statement was not mapped.
Introduction
This research was performed first time in Karachi, Pakistan and prepared for Student poster of NI2012 submissions.
NI2012 will be the perfect place to poster the study result and share the point of view.
Description
The purpose of this study was to analyze the narrative nursing records by cross- mapping to ICNP 2.0 in
maternity unit to identify the terms which can expressed by ICNP concepts in one of the tertiary hospital,
Pakistan.
The accurate nursing documentation facilitates effective communication between nurses as well as among
health care providers. However, paper- based nursing notes often unreliable due to incompleteness and
redundancy, moreover, it is difficult to retrieve or compile them without standardized language. Therefore, it
is imperative to adopt standardized nursing classification for establishing electronic nursing documentation
by analyzing the current nursing notes which would be the first foundation.
Narrative nursing notes were collected from 25 obstetric inpatients after discharged. These nursing notes have been
decomposed into single sentence and classified three parts regards as concept which were nursing phenomena,
nursing intervention and contextual information. And then unified sentences were combined which redundant and
repeated. Finally, found concepts were cross- mapped to ICNP 2 in terms of 7 Axis.
The result showed that total numbers of nursing statements were 4,263 and after unifying the sentences, numbers of
Nursing Phenomena statements were 135, Nursing Intervention statements were 228 and contextual information
statements were 62. And their redundancy rate was 10.3 times. After cross-mapping, 219 (61.3%) statements were
mapped completely, 137(38.4%) statements for partial mapping and only one unified (0.3%) statements were not
mapped.
Finding of this study represents an effective method for analyzing narrative nursing notes; furthermore, the ICNP
is covering most of nursing concepts currently as reference terminology. It showed the usability and applicability of
ICNP, ultimately, there is a high feasibility to adopt standardized nursing language within the electronic nursing
documentation near future.