• Perspectives in Nursing Science
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• v.9 no.2
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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.

• Journal of the Korean Institute of Intelligent Systems
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• v.22 no.4
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• pp.468-475
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• 2012

Nurses have performed their nursing practice according to the standard guidelines such as NANDA, NIC, and NOC, and recorded the information on nursing process into EMR system. In particular, NANDA, nursing diagnosis taxonomy, has difficulty expressing nursing diagnosis in detail because it represents abstract concepts of nursing diagnosis. So, the hospitals in KOREA have developed and used the list of nursing diagnosis on their own without referring the international standard terminologies, and it caused the delay of computerization of nursing records. Therefore, we proposed a ontology development methodology on nursing diagnosis based on NANDA and SNOMED-CT. The developed ontology, systematically developed with the frequently used nursing diagnosis terminologies in each hospital, based on the proposed methodology enables knowledge expansion and interoperable exchange of nursing records between EMR systems. We developed an ontology using the 112 nursing diagnosis terms defined by extracting and refining information on nursing diagnosis recorded in Kyungpook National University Hospital. We also confirmed the content validity and the usefulness of the developed ontology through expert assessment and experiment.