Abstract:

Objective To explore the application analysis on the use of clinical care classification system for nursing undergraduates about medical records of Alzheimer’s disease. Methods Two teachers collected medical records and developed standardized terminology reference criteria in advance，after pre-experiments，medical records were distributed by drawing lots. Based on the clinical care classification，116 full-time nursing undergraduate students enrolled in 2022 analyzed the patient’s medical records and coded relevant nursing diagnosis，nursing measures and nursing outcomes，the correct rate of coding and the error distribution of coding were counted. Meanwhile，semi-structured interview was conducted with students to understand their experience in using clinical care classification. Results A total of 9 502 nursing terms were coded and analyzed by 116 students，including 1 276 nursing diagnoses，6 950 nursing measures，and 1 276 nursing outcomes. The highest coding accuracy rate of students was 100%，the lowest correct rate was 58.82%，and the average correct rate was 88.18%. The coding errors in nursing diagnosis were mainly concentrated in thought processes alteration，cerebral alteration，injury risk，etc.，while the coding errors in nursing measures were mainly concentrated in categories of nursing measures such as activity，physical regulation and safety. Students believed that clinical care classification could reflect the steps and content of nursing procedures and could cover the care behavior of most Alzheimer’s disease patients. There were certain difficulties in mapping and analyzing clinical care classification in the medical records，but theoretical and clinical exploration could promote the learning and application. Conclusion Undergraduate nursing students are generally able to understand and apply the clinical care classification system，analyze and apply it in the medical records of Alzheimer’s disease patients. This study provides certain reference value for the teaching of standardized nursing terminology.

Key words: Nursing Undergraduates, Clinical Classification Care System, Alzheimer Disease