میزان انطباق و قابلیت استفاده از سیستم طبقه‌بندی مراقبت‌های بالینی در مستندسازی مراقبت‌های پرستاری در بخش‌های مراقبت‌های ویژه‌ی نوزادان

Introduction: Development of electronic health records and application of international terminologies to obtain semantic generalization is one of the challenges of healthcare system.Therefore, it seems essential to register nursing care in electronic health records in a standard fashion and on the basis of one of classification systems. The aim of this research was validating of mapping and usage ability of Clinical Care Classification system in nursing documentation in Neonatal Intensive Care Units. Methods: This descriptive research was a content analysis study and research population, were babies' records and nursing care were performed on hospitalized newborns in Neonatal Intensive Care Units. Sampling was done by surveying 503 reports and extracting nursing care for hospitalized infants in the first quarter of 1390 and observational checklists were used to access 48 unregistered care in mentioned above records. Data gathering tools were questionnaire and observational checklists that their validity and reliability were assessed through content validity and inter-rater coefficient. Recorded reports of nurses were analyzed by content analysis and obtained expressions were adapted with the diagnoses and coding system’s interventions and clinical care classification. Credibility of gain adaption was approved using the Delphi method in two rounds. Results: Findings showed most components of care in Neonatal Intensive Care Units were related to respiratory care and drug administrative component (16.5 %). The most frequent of nursing diagnoses was related to respiratory condition of infants such as mechanical ventilation-dependency (21.1%) and the most nursing interventions were related to ones that were performed by physician order such as blood sampling and medication (23.9 %). In next step, performed nursing cares in Neonatal Intensive Care Units were specified and adapted to classification system of clinical care and adaption rate was 36.1%. Low adaption rate showing lack of standard record and as result coding and classification system is required to register care in standard fashion. Conclusion: Using coding system and classification of nursing care, the problems of lack of usage the nursing process framework, lack of standard care and problems of registration the nursing reports in electronic health record will be solved largely. Key words: Intensive Care Unit, Neonatal; Documentation; Classifications