• Proceedings of the Korean Information Science Society Conference
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• 2001.04b
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• pp.337-339
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• 2001

간호진단, 중재, 결과로 이어지는 간호 프로세스에서 가장 전문적인 지식을 요구하는 간호진단 업무를 지원하는 전산시스템에 대해 우리나라에서도 많은 연구와 시도가 있었다. 그러나 기록만 전산화되었거나 부분적으로 표준화된 데이터를 이용함에 따라 간호진단업무에 능숙하지 않은 간호사의 경우 전산화를 통한 진단업무효율 향상을 기대하기 어렵다. 이에 우리는 간호진단의 적중률을 높이기 위해서 간호 프로세스의 표준데이터와 사례를 기반으로 추론하는 간호진단시스템을 제안한다. 표준 데이터를 이용하여 예상되는 간호진단을 1차적으로 검색한 후, 다시 사례데이터베이스를 기반으로 하여 1차 검색의 결과를 보완하는 방법을 이용하고 있다.

• Korean Journal of Adult Nursing
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• v.18 no.4
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• pp.533-542
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• 2006

Purpose: The purposes of this study were to investigate medical records and to develop care records for management of patients with chest pain in the emergency department. Method: Retrospective review of the 42 medical chart of patients presented to the emergency department with chest pain were used. The collected data were analyzed with a frequency of items in the medical records. Results: In a frequency analysis of recorded items for doctors' chest pain assessment during history taking, the history/risk factors was the highest rank. The following ranks were 'commenced with when/timing, extra symptoms, place, nature, stay/radiate, alleviate/aggravate, intensity' in sequence. In a frequency of recorded items in nurse's progress notes according to nursing actions, the 'checking/monitoring' was the highest rank. The following ranks were 'performing, administering/injecting, referring/arranging, testing, preparing/catheterizing, teaching/informing' in sequence. Chest pain care records for the emergency department was designed, based upon data analysis and literature review. Conclusion: The designed records can be a rapid and effective approach tool for assessment and recording of patients with chest pain. Further research is necessary for evaluating the designed chest pain care records.

• Journal of Hospice and Palliative Care
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• v.7 no.2
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• pp.200-213
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• 2004

Purpose: The purpose of this study was to create an electronic nursing record form to build a hospice nursing process database to be used in the u-hospital EMR system. Specific aims of the study were: 1. To generate a complete, accurate, and simple electronic nursing record form. 2. To verify its appropriateness following documentation with the standardized hospice protocol. 3. To verify its validity and finalize the hospice nursing process database through discussion among hospice professionals. Methods: Nursing records from three independent hospice organizations were collected and analyzed by five expert hospice nurses with more than 10 years of experience, and a nursing record database was developed. This database was applied to 81 hospice patients at three hospice organizations to verify its completeness. Results: 1. An electronic nursing record form with completeness, accuracy, and simplicity was developed. 2. The completeness of the standardized home hospice service protocol was 95.86 percent. 3. The hospice nursing process database contains 18 items on health problems, 79 items on related causes and major symptoms, and 229 items on nursing interventions. Conclusion: The new nursing record form and database will reduce documentation time and articulate and streamline the working process among team members. They can also improve the quality of hospice services, and ultimately enable us to estimate hospice service costs.

• Journal of Digital Convergence
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• v.10 no.8
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• pp.257-264
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• 2012

This study was conducted to arrange the basic data for the ways to operate the effective nursing programs and reduce job stress by grasping the awareness, satisfaction and job stress of the nurses due to the introduction of EMR(EMR : Electronic Medical Record) system and clarifying the relationship among them. Methods: Of the hospitals which introduced EMR, the study was conducted for 356 nurses who used EMR in a university hospital in D city and the data was collected from June 1 to June 30. The collected data was analyzed with real number, percentage, T-test, ANOVA, and Pearson correlation coefficient. Results: The results of the study above, it could be certified that the higher the satisfaction and awareness of the users of EMR were, the more the job stress of them decreased. Therefore, the qualitative nursing should be provided to the patients by reducing job stress with the improvement of the awareness and satisfaction of the nurses of EMR, and shortening the time in keeping the records of patients, in order to enhance the satisfaction of EMR, there should be a proper management, such as a regular EMR education, and there must be the ways to reduce the job stress of the nurses and strengthen the satisfaction of EMR.

• Journal of Korean Academy of Nursing
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• v.37 no.6
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• pp.883-890
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• 2007

Purpose: The purpose of this study was to identify the entity of critical care nursing practices through analyzing nursing statements described by electronic nursing records in a MICU. Methods: 176,459 nursing statements of 188 patients during a 6 month-stay were analyzed statement by statement according to the nursing process(nursing phenomena, nursing diagnosis, & nursing activity) and 21 nursing components of Saba's Clinical Care Classification. Results: Among 176,459 single statements, the statements of nursing activity ranked first in number. The contents of the statements were analyzed and categorized by main themes. Among 489 categorized themes, the number of themes of nursing phenomena statements was the highest. When analyzed by Saba's clinical Care Classification, the nursing statements mainly included a physiological component. Among 21 components, the respiratory component ranked in the first position in nursing phenomena, nursing diagnosis and nursing activity. The extra statements not included in the 21 components were 9,294(15.1%) in nursing phenomena and 21,949(22.7%) in nursing activity. Most are statements related to tests and the doctor. Conclusion: The entity of MICU nursing practice expressed by electronic nursing records was mainly focused on physiological components and more precisely on respiratory components.

• Research in Community and Public Health Nursing
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• v.20 no.1
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• pp.105-111
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• 2009

Purpose: The purpose of this study was to identify minimum datasets for ulcer assessment and to map the minimum datasets to paper-based nursing records for pressure ulcer care in homecare setting. Methods: To identify minimum datasets for pressure ulcer assessment, the authors reviewed four guidelines for pressure ulcer care. The content validity of the minimum datasets was assessed by three homecare nurse specialists. To map the minimum datasets to nursing records, the authors examined 107 pressure ulcer events derived from 45 pressure ulcer patients who received home nursing from two hospitals in Gyeonggi Province. Results: The minimum datasets for initial assessment were anatomical location, stage, size, tissue, exudate, condition of periwound skin, undermining, odor, and pain. 'Location' was recorded best, accounting for a complete recording rate of 98.1%. 'Exudate' and 'pain' showed the poorest record, accounting for 2.8% and 0%, respectively. The minimum datasets for progress assessment were wound size, tissue, and exudate, each accounted for 31.8%, 2.8%, and 4.7%, respectively. Conclusion: This study concluded that data on pressure ulcer assessment was not sufficient homecare and it can be improved by adopting minimum datasets as identified in this study.

• Journal of Home Health Care Nursing
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• v.3
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• pp.5-38
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• 1996

The objective of this study is to develope the record forms for the home care nursing. Through the literature review and 4 times of workshop participated with the health practitioner and nursing professors from July 1993 to March 1995, the standands of home nursing care, initial assessment tools, progress notes by diseases and the referral sheet were developed. The Community health practitioner were trained for home nursing care and participated with 5 nursing professors in the workshop to validate the content of the record forms. It is suggested that the more refinement of these record forms fased a defined conceptual framework in the various home nursing area is needed in the future.

• Journal of Korean Clinical Nursing Research
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• v.19 no.3
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• pp.345-356
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• 2013

Purpose: To provide clear estimates of the adoption and use of electronic nursing records (ENRs) with standard terminology in Korea and identification of the scope and use as well as perceived or potential benefits of ENRs. Methods: A survey was done of 733 hospitals at three levels: tertiary advanced hospitals, general hospitals, and community hospitals. After performing a literature review a modified version of an existing survey tool was used for 2 months in 2012. The collected information related to EHR functionality and coverage of nursing documentation and nursing process, application of standard terminology, and perceived satisfaction and benefits of ENRs. Results: The response rate was 39.4% (289/733), and 202 hospitals (70.1%, 95% CI64.8~75.5%) of the respondents had ENR systems (82.5% of tertiary hospitals, 66.7% of general hospitals, and 70.1% of community hospitals). Out of these hospitals less than 10% had ENRs fully covering nursing documentation. The adoption rate of standard terminology was 55%, and hospital satisfaction with ENRs was 70%. But personalized care was identified as needing improvement in ENRs. Conclusion: The ENR adoption rate was high but there are many potential opportunities for improving ENR systems in terms of the data standardization and personalized care.

• Journal of Home Health Care Nursing
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• v.10 no.2
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• pp.103-112
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• 2003

Purpose: The purpose of this study was to develope nursing activities record to improve home care nursing for postpartum women following a Cesarean section and newborns. Method: This study for instrument development had three phases: first, selection of nursing activities according to intervention, second, validation of the preliminary home care nursing activities, and third. application of the home care nursing activities. The subjects for validaton were 137 home care nurses and clinical nurses in department of maternity. Result: By Fehring's method, 116 nursing activities according to 19 interventions were included in the preliminary nursing activities record. Among them, 51 critical nursing activities and 65 supporting nursing activities were chosen. During the final process of validation, 121 nursing activities were included. Conclusion: In order to have systemic standardization of this record forms, replication and application in the various home nursing area is need in the future.

• Journal of East-West Nursing Research
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• v.17 no.1
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• pp.66-70
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• 2011

Purpose: The aim of this study was to examine the types of nursing problems in oriental nursing practice. Methods: This study employed a descriptive survey design. Nursing documentation was retrospectively reviewed for patients discharged from an oriental medicine hospital during three months. Nursing diagnoses documented were mapped into the Clinical Care Classification System. Data were summarized using descriptive statistics. Results: Data were collected from 110 patients using nursing documentation. The number of nursing diagnoses documented was 204 with a mean of 1.9 per patient. The frequently occurring nursing diagnoses were 'risk for trauma' (48.0%), 'pain' (13.7%), and 'urinary elimination alteration' (7.8%). According to the Clinical Care Classification system, the safety component (51.5%) was the most common nursing problem in oriental nursing practice. Conclusion: The study finding suggested that major nursing problems in oriental nursing practice were related to patient safety. Therefore, oriental nursing education on patient safety should be emphasized to improve the quality of nursing care in oriental medicine hospitals.