Analysis of nursing assessment terminology for neurological conditions and its cross-mapping with the International Classification of Functioning, Disability and Health (ICF): A multi-centre cross-sectional study.
Hongying Pan, Shanni Ding, Xiaona Liu and 3 others
PMID 33760375WHAT IT FOUND
Most neurological nursing assessment terms matched ICF categories, but electronic records often missed them.
Orientation and fine motor skill were assessed in all 377 patients yet recorded in only 10 and 3 cases.
Key findings
01Of 56 neurological nursing assessment concepts, 54 matched ICF categories, with 37 the same and 9 similar.
02Orientation and fine motor skill were assessed in all 377 patients but recorded in only 10 and 3 cases, respectively.
0321 nursing assessment concepts closely related to neurological conditions did not appear in existing electronic nursing assessment records.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
Only patients from three hospitals in Zhejiang, China, were studied, so the findings may not apply to other regions or care systems. The hospitals used different electronic assessment systems, so missing records may reflect system differences rather than one common standard. The study mapped terminology and recording rates; it did not measure patient outcomes or whether recording these terms improves care. Some terms were assessed but not recorded, so the paper cannot show whether nurses omitted them or the systems lacked fields.
Declared interests
No author conflict-of-interest declaration is supplied; the article is tagged as non-U.S. government research support.
The easy way to misread this
Do not read the 96.4% ICF match as evidence that using ICF improves patient care. The study only mapped existing nursing terms and showed many were not recorded.