Type and Contents of Health Records and Recording Tendencies of Nurses in Small-Scale-Enterprises

소규모 사업장 보건관리 산업간호사의 업무서식과 기록행태

This study was carried out to investigate the types of health documents for nurses, the content of informations in the documents, and writing behaviors of occupational health nurses. Health documents were collected from 7 nurses who were working in 7 group occupational health agencies (GOHA) located at Seoul and Inchon area in Korea. The collected health documents written in January to June 1999 were analyzed, and revealed the following results. 1) The occupational health nurses were using 9 to 18 different types of health documents. The contents of the documents were considered quite similar to each other with slightly different headings and items to record. Among different types of health documents. Health Management Card for Workplace', Nursing performance sheet and Workplace environmental checklist were in common among nurses and were used for content analysis. 2) The 'Health Management Card for Workplace' was the only formal sheet of small-scale-enterprises (SSE) for health management, in which health and safety related information was recorded. The information on nursing services were recorded on the Nursing performance sheet, which has slightly different names on each type with similar contents. The Workplace environment checklist was for the information on general work environment management and mainly status of workplace hygiene. This checklist is to be used by or with nurses among the 3 types health professional team such as doctor, hygienist, and nurse, but it seemed not being used frequently by nurses. 3) Analysis on recording tendencies of nurses revealed that the writing styles of occupational health nurses were associated with 'memo' using a few number of words and short sentences. The amount of information by this kind of recording style was considered not enough for health management situation. The possible reasons for nurses to use this writing style might be insufficient time for recording and improper designed format of health documents. Because nurses working in SSE spend more time on the roads to visit workplaces, nurses may not found enough time for recording properly within their working time. In addition, the health records were designed to focus on the frequency of nurse's performance in certain types of work rather than on the method they used to deal with health problems. In conclusion, this study suggests that some steps are necessary to develop health documents and recording system which is appropriate to occupational health nurses. The educational need for nurses on appropriate recording behavior is also recommended.