• 성인간호학회지
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• 제21권3호
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• pp.349-354
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• 2009

Purpose: The purpose of this study was to determine core nursing intervention in nursing records and to compare perceived nursing intervention priority and nursing intervention frequency of general surgery department. Methods: Subjects were 70 nurses who work in the general surgery department. Data was collected using a nursing intervention classification and analyzed by frequency and mean. Results: The most frequent nursing interventions of nursing records were orderly risk management, coping assistance, tissue perfusion management, skin/wound management and nutrition support. Important nursing interventions were tissue perfusion management, respiratory management, electrolyte acid-base management, elimination, peri-operative care. The most frequent nursing interventions were drug management, peri-operative care, risk management, tissue perfusion management, patient education. Conclusion: This study found that nursing records were different from intervention priority and nursing frequency. So further study is needed for finding focused intervention of specific subjects and differences with priority of nursing and frequency of nursing.

• 보건의료생명과학 논문지
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• 제10권1호
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• pp.39-47
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• 2022

본 연구는 전자의무기록시스템 인증관리포털에서 인증을 받은 의료기관 종사자들을 대상으로 직종별 "전자의무기록시스템 인증제에 대한 인식도", "시스템 기능성(Functionality)"의견을 수렴하여 전자의무기록시스템 기능에 대한 국가적 표준과 적합성 검증을 통해 EMR 시스템 표준화사업의 목표인 의료의 질 향상, 국민건강 증진에 기여할 수 있는 기초자료를 제공하기 위하여 수행되었다. 연구분석자료는 922건의 설문조사가 이용되었으며 여성이 74%, 연령은 30~39세가 32.1%, 간호직이 48.9%, 근무연수는 5년~10년 27.4%로 가장 높은 비율로 나타났다. EMR 인증제도 인식에 대한 직종별 인식은 간호직에서 가장 높게 나타났으며, EMR 시스템 기능성에 대한 직종별 인식에서도 6개의 항목 중 5개 항목에서 간호직이 가장 높게 나타났다. EMR 시스템의 주된 이용자인 의사직에서는 전체 항목에서 낮은 평균을 보였으며, EMR 시스템의 인증제도뿐만 아니라 EMR 시스템 인증제도의 각 항목별 인증기준에 대한 교육이 필요한 것으로 사료된다.

• 간호행정학회지
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• 제2권1호
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• pp.73-96
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• 1996

In the complexity and diversity of modern society, there is an urgent need for an information system which can systematically collect, manage and analyze data. Especially in the discipline of nursing, a nursing informarion system is necessary to maximize nursing resources and improve nursing care in the present system which is faced with increases in client needs and multiple changes in hospital environments. This research was done to provide a basis for the development of an integrative nursing information system for the future, by designing dababases items which were extracted from an analysis of the ward nursing information system on general wards excluding the OPD, ICU, OR and CSR with functions using a different system from the wards, and the design of output screen used the database items. The ward nursing information system was analysed through analysis of nursing practice related to recordings, such as the worksheet, kardex, and other nursing practice recordings, on 25 wards. The development of the database was the part of the construction of hospital information system and used the database development life cycle which is related to the system development life cycle. The database development steps included selection of database management system and design of a physical database following the principles of the order communication system which is been developing at Y University Hospital. Conceptual database and Logical database were designed using the base of 25 data items and fields derived from analysing the worksheet, the data items and fields derived from the kardex and other nursing practice recording, from these 19 data base tables were framed through transforming the relational database. Through this process, four types of output material for nursing practice recording which nurses can carry and use during their nursing practice were produced.

• 중환자간호학회지
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• 제1권1호
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• pp.73-83
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• 2008

Purpose: Purpose of this study was to analyze the nursing focuses for standardization of ICU nursing records. Methods: The data were collected from 1,000days'nursing records of 197 ICU patients at a tertiary hospital in Seoul. Nursing focuses were unified at the consulting group meeting and they were cross-mapped with the NANDA nursing diagnoses. Results: The 62 nursing focuses in 7 NANDA categories were extracted from nursing record. Among total nursing focuses 41 correspond to the NANDA nursing diagnoses and 21 were added to ICU nursing focuses. The 10 most frequently used nursing focuses are 'Ineffective airway clearance', 'Impaired gas exchange', 'Ineffective tissue perfusion: cardiopulmonary', 'Ineffective breathing pattern', 'Ineffective tissue perfusion: renal', 'Ineffective infant feeding pattern', 'Risk for impaired skin integrity', 'Hyperthermia', 'Impaired skin integrity', 'Decreased cardiac output', Conclusion: Nursing focuses list of ICU was extracted from the result of this study. These nursing focuses might form a framework for development of research-based assessment guideline and care plans for ICU patients through standardization of nursing records.

• Perspectives in Nursing Science
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• 제9권2호
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• pp.146-153
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• 2012

Purpose: The aims of this study were to analyze the frequency of standard nursing statements used in the Electronic Nursing Record (ENR) and to evaluate the degree of satisfaction by users of the ENR system. Methods: We retrospectively reviewed the ENR of 1914 patients who were admitted to our center between 1 May 2011 and 31 May 2011. Additionally, we collected questionnaires from 100 doctors and 300 nurses to evaluate the satisfaction of the users. Results: The frequency of use for the following standard nursing statements was investigated: standard nursing assessment statements (43.6%), standard nursing diagnosis statements (61.8%), standard nursing plan statements (46.7%), standard nursing intervention statements (56.9%), and standard nursing evaluation statements (41.7%). The mean satisfaction score was 3.03 out of 5 in the nurse's group, and 3.11 in the doctor's group. The nurses said the advantages of the ENR system were as follows: easy to access, informative, and standardized terms. However 75.7% of the nurse answered that they cannot express actual nursing situations exactly with the currently limited standard nursing statements. Conclusion: Development of various standard nursing statements is needed to meet the demands of the users. As a result, the use of the ENR system would become easier and more efficient for its users.

• 기본간호학회지
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• 제8권3호
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• pp.402-415
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• 2001

The purpose of this study was to identify nursing diagnoses and nursing interventions that are found in the home health care patients, and to establish a basis for a standardized Nursing Intervention List that would help nurses doing home health care nursing. For this study, the records of 150 home health care clients who were discharged, from the Home Health Care Center at Yonsei Medical Center, between January to July. 2001 were analyzed. Of the 43 nursing diagnoses recorded for these clients are 43, the most frequent diagnoses were in the area of Exchanging. There were 2.814 nursing interventions which is a mean of 4.73 nursing interventions Per diagnosis. We confirmed that most of the interventions were related to 'education' and 'advice'. We present a Home Health Care Nursing Intervention List that was developed based on the results of this study. It has the five 5 criteria of the ICNP classification, Observing, Management, Performance, Caring, and Informing.

• 한국산학기술학회논문지
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• 제16권11호
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• pp.7447-7455
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• 2015

본 연구는 간호학생의 재난준비도와 재난간호 핵심수행능력 및 교육요구도를 파악하여 재난간호 교육과정 개발을 위한 기초자료를 제공하고자 시행된 조사연구로 D 지역 간호대학 및 간호학과 4학년 252명을 대상으로 시행되었다. 연구결과 대상자의 재난간호 수행능력은 평균 2.76이었으며, 재난간호 수행능력중 "재난상황시 문서기록절차"가 2.34, "소속기관의 재난관련지침"이 2.37로 가장 낮았다. 또한, 대상자의 재난준비도는 평균 2.14이었으며, 가장 낮은 항목은 "집에서의 재난대피연습" 항목이었다. 대상자의 재난간호 핵심수행능력에 영향을 미치는 요인으로는 재난준비도(${\beta}$=.48), 재난교육요구도(${\beta}$=.21), 성적(${\beta}$=.26), 재난교육 여부(${\beta}$=-.11)로 나타났다. 본 연구결과 간호학생의 재난준비와 재난간호 핵심수행능력은 부족한 실정으로 나타났으며 재난간호에 대한 교육이 절실히 필요하며 간호대학생을 위한 재난간호 교육과정 개발을 위한 교육내용에 대한 연구가 필요하다.

• 임상간호연구
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• 제21권3호
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• pp.377-388
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• 2015

Purpose: To identify user requirements for electronic nursing record (ENR) systems so as to ensure system usability. Methods: A mixed methods approach were applied in three steps : (i) task and workflow analysis with literature review of nursing documentation, (ii) literature reviews of system usability, and (iii) Use Case idenfication and consensus-based validation. We analyzed the nursing activity logs collected from a time-motion investigation of six hospitals. The Use Cases were validated by eight clinical experts from different hospitals and two experts from academia in a sequential Delphi survey. Consensus was achieved for the significance score and agreement among the panel. Results: Eight task groups and patterns of task flow were observed, which were translated into nine Use Cases. The specification of Use Cases was derived from principles, guidelines, and recommendations on nursing documentation and electronic health record systems, which was organized into three requirements of each Use Case: functionality, information, and design characteristics. Each Use Case achieved an agreement of 50~70%, and significance scores of 4 or 5 on a 5-point Likert scale. Conclusion: The nine Use Case identified were considered to be important and adequate in terms of both clinical and informatics contexts.

• 대한간호학회지
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• 제7권1호
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• pp.1-9
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• 1977

Primary function of health record is that as tool of communication between the health processionals with the mutual goal, the promotion of health care standard. Studies have been carried out world over oil tile subject, among those, Weed's Problem-Oriented Health Record is considered a paramount achievement. This study was designed to assess tile possibility of implementing tile problem-oriented health record system through ail experiment in order to provide data for nurse administrators infiltrating reformation of recording system and format. Record of 29 patients admitted at Korea University Hospital, Seoul, from March through June, 1976 for 4 to 14 days were sampled. Nursing notes were recorded by research assistants; senior nursing student trailed extensively by the researcher oil Problem-Oriented Records, oil Problem Oriented Nursing Record format (experimental group) and analysis were carried out comparative, with that of traditional nursing records noted by other nursing personnel (control group) on the same patient. Attitude towards Problem Oriented Nursing Record system and format were attained through questionaries responded by the 51 research assistants. Results are as fellows: Comparative analysis revealed that: 1. Assessment of patients' health problems recorded significantly more in traditional records. 2. Focus of health Problem differed; traditional records slowed significantly higher frequency in medical and procedure as focus while problem oriented records on nursing focus problems. 3. Problem- Oriented records were better organized, Mean value scores of attitude towards Problem- Oriented Records revealed that: Positive value scores on all 4 categories: 1) Assessment of nursing needs, 2) Nursing care planning 3) Patient progress assessment and 4) Tool of teaching and learning revealed that the Problem-Oriented Nursing Record is positively accepted by tile respondents. Recommendation Further experiments on implementation of Problem- Oriented Health Record are recommended: experiment involving all health professionals, in larger scope and longitudinal.

• 임상간호연구
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• 제19권3호
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• pp.369-382
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• 2013

Purpose: This study aimed to develop an educational program on nursing records especially focused on legal issues, and to test the effects of the educational program on nurses' knowledge, performance, and behavior. Methods: A textbook on legal issue-focused nursing records and an instrument with 36 items rated on a 5-point scale (1-5) for measuring the nurses' charting-related performance and behavior were developed from November 2007 through March 2008. A nonequivalent control group pretest-posttest design was employed to test the effects of the education program. Knowledge was self-reported by the Nurse Charting Knowledge Scale, while performance and behavior were measured by their nurse managers. The pretest and posttest were conducted from March through May in 2008. A total of 226 Korean nurses participated in this study. Data were analyzed with descriptive statistics, t-test, Chi-square, paired t-test, Spearman's coefficient, and multiple regression. Results: Nurses who received the intervention showed greater levels of knowledge (t=10.28, p<.001), performance (t=2.53, p=.013), and behavior scores (t=3.07, p=.002) than those of the control group. The factors influencing the improvement of knowledge were 'job attitude' (t=-3.32, p=.001) and 'career in present unit' (t=2.95, p=.004). The factor influencing the improvement of performance was 'career in present unit' (t=-3.39, p=.001). The factor influencing the improvement of behavior was 'job attitude' (t=-3.46, p=.001). Conclusion: The educational program on legal issue-focused nursing records was effective in improving nurse charting-related knowledge, performance, and behavior.