Journal of Korean Clinical Nursing Research (임상간호연구)

Hospital Nurses Association (병원간호사회)
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Evaluation on the Record Completeness of the Nursing Process in Electronic Nursing Record for Patients Undertaken Gastrectomy

전자간호기록에 사용된 간호과정 완성도 분석 - 위절제술 환자를 중심으로 -

  • Park, Ihn Sook (Department of Nursing, Seoul National University Hospital) ;
  • Yoo, Cheong Suk (Department of Nursing, Seoul National University Hospital) ;
  • Lee, Soon Hyeung (Department of Nursing, Seoul National University Hospital) ;
  • Woo, Kyung Shun (Department of Nursing, Seoul National University Hospital) ;
  • Joo, Young Hee (Department of Nursing, Seoul National University Hospital) ;
  • Choi, Woan Heui (Department of Nursing, Seoul National University Hospital) ;
  • Kang, Hyun Sook (Department of Nursing, Seoul National University Hospital) ;
  • Jung, Mi Ra (Department of Nursing, Seoul National University Hospital) ;
  • Kim, Hee Jin (Department of Nursing, Seoul National University Hospital) ;
  • Park, Mi Ok (Department of Nursing, Seoul National University Hospital) ;
  • Lee, Su Hee (Department of Nursing, Seoul National University Hospital) ;
  • Ahn, Seon Yeong (Department of Nursing, Seoul National University Hospital)
  • Received : 2009.09.30
  • Accepted : 2009.10.23
  • Published : 2009.12.31
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Abstract

Purpose: This study was conducted to evaluate the record completeness of the nursing process in the Electronic Nursing Record(ENR) in a university hospital. Methods: We compared nursing statements documented in 2004 with those from the year 2007, given the fact that the ENR system had been utilized since 2004. The ENRs of 35 gastrectomy patients in each year were selected for evaluation. The selected data were 11,822 nursing statements in 2004 and 27,870 in 2007. Results: The number of nursing records which documented the whole nursing process completely was 4,010 (48.3%) in 2007, whereas 513 (5.9%) in 2004 (p<.001). The number of incomplete records in 2004 was 8,142 (94.1%), while 4,300 (51.7%) in 2007 (p<.001). The number of nursing diagnoses was 846 in 2004 and 4,313 in 2007, which increased in number more than 5 times. The most frequently used diagnoses were 'pain', 'risk for infection' and 'risk for ileus' in both years. Conclusion: There was a significant increase in the record completeness on nursing process in 2007 compared to the records in 2004. The reasons for this increase are attributed to nurse training for encouraging to complete recording and nursing record auditing.

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References

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