主管:国家卫生健康委员会
主办:国家卫生计生委医院管理研究所
中国科学引文数据库(CSCD)来源期刊
中国科技论文统计源期刊 中国科技核心期刊
《中文核心期刊要目总览》入选期刊

Chinese Nursing Management ›› 2020, Vol. 20 ›› Issue (6): 911-916.doi: 10.3969/j.issn.1672-1756.2020.06.023

• Information Management • Previous Articles     Next Articles

Applicating of Clinical Care Classification system in nursing practice of orthopedic ward

HAN Haiyan, GAO Xiuxiu, YANG Lei, CONG Peilong   

  1. Orthopaedics Department, He'nan Hongli Hospital, Changyuan, He'nan province, 453400, China
  • Online:2020-06-15 Published:2020-06-15
  • Contact: E-mail:61194255@qq.com

Abstract: Objective: To explore the application of Clinical Care Classification (CCC) system in orthopedic nursing practice. Methods: The data of the nursing care records using the CCC Full Intelligent Care Information System from March 2019 to July 2019 were analyzed with a total of 263,402 nursing document entries. Results: The data from the CCC system showed that in the nursing diagnosis, the physiological factors accounting for 59.99%, the functional factors accounting for 26.41%, the healthy behavior factors accounting for 9.32%, and the psychological factors accounting for 4.28%. The care measures involved in the integrity of the skin among the nursing elements were the highest (25.47%), followed by the active category (22.25%), the safety category (15.58%) and the body regulation category (14.16%), of which the assessment monitoring category accounted for more than half of the total care measures (50.88%). Nursing implementation measures accounted for 27.43%, while teaching guidance and management referral category measures accounted for 12.03% and 9.66%, respectively; There were significant statistical differences between the expected goal of nursing and the actual outcome. Conclusion: The CCC can be used to record nursing data and write electronic medical records in intensive care unit practice, and can provide personalized care for patients, analyze frequency of each care content, and reduce the amount of work recorded by clinical nurses in nursing documents. It is beneficial to the establishment and analysis of big data in nursing. The application of CCC can promote the clinical practice of orthopedic nursing and the development of nursing research.

Key words: Clinical Care Classification; nursing terminology; orthopedic ward; nursing practice

CLC Number: 

  • R47