ABSTRACT
Objective To analyze the language structure of nursing records and the application of defined vocabulary in nursing records of community child care,and to explore the possibility of structuralization and standardization of community nursing records by researchers' consulting International Classification of Nursing Practice (ICNP(R)2.0).Methods Convenient sampling method was used.A total of 432 handbooks about child health care were extracted from three community health service centers in Liaoning province.By analyzing the nursing records,the vocabulary was selected,and a coding book was built.Then researchers compared them with ICNP(R)2.0 Chinese version.Results Totally 567 terms were extracted.All phrases in nursing records about community child health care can be classified into three categories and seven shafts,which were nursing phenomenon,nursing action and nursing outcome.Our community nursing records about child health care could not fully meet shaft level of nursing record writing requirements from the International Council of nurses.Only 146 records were labeled as perfect fit with ICNP(R)2.0 terminology,223 records as not fit at all.The difference of different levels of suitability distribution about nursing phenomenon,nursing action and nursing outcome had statistically significant difference.Words of able to adapt and can't adapt about nursing action had larger proportion.Words that can't adapt about nursing phenomenon and nursing outcome had larger proportion.Conclusions There is still certain gap between domestic nursing records and ICNP(R)2.0 terminology.The list of terms from comparison nursing records about community child health care with ICNP(R)2.0 can lay the foundation for nursing language system structure and perfect community nursing record language in our country.