護理記錄是病歷記載的重要部分，建立結構性和標準化共同護理語言，對護理專業之發展是迫切需要的業務，電子化護理記錄有方便資料之存取與應用等優點。國際護理協會發展國際護理作業分類系統成為國際護理語言，我國於2002年10 月完成ICNP Beta 2中譯版瀏覽器，推動電子化護理記錄尚處於萌芽階段，能否適用在婦科臨床實務，有待臨床驗證。本研究為描述性研究，收集某一區域教學醫院婦科病歷之護理記錄進行研究。研究目的在探討紙本護理記錄以ICNP Beta 2中譯版瀏覽器轉譯後，其適用性、完整性及護理人員對婦科住院婦女最常提供之護理現象及其護理行動。資料共收集62本病歷護理記錄，包含6327句，每一句分類為護理現象或護理行動。其中護理現象1918句（30.3 %），護理行動4409句（69.7 % ），二者比例為1: 2.3。依適用性分析，能完全符合2041句（32.3 %）、意義相同2457句（38.8 % ）、需輸入字句1663句(26.3 % ) 、無法轉譯166句（2.6 %），顯示大多數護理字句能以ICNP轉譯。評價軸向之完整性，護理現象包含焦點、判斷、可能性三軸向僅490句（佔25.5 %）；護理行動包含行動類型4307句（佔97.7 %）。護理人員對婦科病人所提供之護理活動，生理層面多於心理、社會及靈性層面。建議ICNP軟體之應用需要再修正組織結構，避免軸向重複及減少結構的複雜性，並期待不同等級醫院之婦科參與更多臨床驗證。

　Establishing a structured and standardized common nursing language is an important task for the nursing profession. A common language will be important as electronic. Although an electronic nursing record system is still lacking in Taiwan, the International Classification for Nursing Practice (ICNP) is becoming the international nursing language. The ICNP Beta 2 version has been translated into Chinese, but a validation of gynecological nursing practice has not been conducted.

　The purpose of this study was to determine the coherence between the ICNP beta 2 Chinese version and paper-based nursing records from one gynecological unit, to validate the completeness between the ICNP beta 2 Chinese version and paper-based nursing records, and to identify the nursing phenomena and nursing actions priorities among gynecological nurses. A retrospective review of the nursing narrative notes of paper records from 62 gynecological patients of one private teaching hospital was conducted. Subsets of terms were abstracted and mapped onto ICNP terms.

　Sixty-two patient records were analyzed and produced 6327 sentences, each sentence was classified as a nursing phenomena or a nursing action. The applicability analysis of abstracted terms was mapped onto ICNP. There was a Perfect fit with 2041 sentences (32.3%), a conceptual fit with 2457 sentences (38.8﹪) , partial fit with 1663 sentences (26.3%) and 166 (2.6﹪) of the sentences were unable to be fit onto the ICNP framework, the majority of nursing notes from the gynecological unit mapped onto the ICNP. The completeness analysis of abstracted terms was mapped onto ICNP. There was 490 sentences（25.5%）of the gynecological patient records nursing phenomena contained all three axes of focus, judgment, and likelihood in nursing phenomena. There are 4307 sentences（97.7%）of the gynecological patient records were mapped onto the nursing action type axis. The sixty-two gynecological nursing records revealed that the numbers of nursing phenomena are proportionally lower than nursing actions by 1 to 2.3. It was found that gynecological nurses pay more attention to physical aspects of care than psychosocial or emotional aspects. Further validation is required to test the applicability of ICNP using records from other gynecological facilities.

　The findings of this study support the applicability of the ICNP Beta 2 Chinese browser for electronic nursing records.

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