• Journal of Korean Academy of Fundamentals of Nursing
• /
• v.13 no.1
• /
• pp.24-32
• /
• 2006

Purpose: This study was a comparative review of the computerized nursing records and paper-based nursing records to examine effects of a nursing process documentation system focusing on patients who have had stroke. Method: First, the researchers collected all the foci from the computerized records and the paper-based records. They selected ten nursing foci, used frequently in both groups and analyzed the number of foci per patient, appropriateness of foci, the number of nursing activities per nursing focus and whether outcomes were described or not in the nursing record. Results: There was fewer errors in nursing diagnosis selection, and a larger number of activities in the records than trle paper based ones. Also, there was a better description of the nursing outcomes in the computerized records. Conclusion: This study suggests that the computerized nursing records is significantly effective in increasing accuracy of the nursing care plan and quality of the nursing record.

• Journal of Korean Academy of Nursing Administration
• /
• v.11 no.3
• /
• pp.335-345
• /
• 2005

Purpose: This study was designed to develop a computerized program for patient classification and record of basic nursing care. Method: The study was carried out from February to May 2004 at the four general wards in A university hospital using three steps; investigation of needs for program development, program design and development, and program application and evaluation. Result: Results of this study showed that users were mostly satisfied with the program and set a high value on the usefulness and performance of this program. Accordingly it was found that this program could be of help to assist nurses in classifying the patients and taking records of their nursing service. Conclusion: The program is likely to contribute to enhance the efficiency in providing appropriate and effective nursing service to the patients by easily identifying the overall particulars of patients and improving repeated manual works. And Record of basic nursing care is a part of several nursing records. As such the continual development on the computerized program for various fields of nursing service is needed.

• Journal of Korean Academy of Nursing Administration
• /
• v.12 no.4
• /
• pp.532-540
• /
• 2006

Purpose: To identify the degree of users' satisfaction with Nursing Information System. Methods: The study is a survey of users' satisfaction with Nursing Information System. The subjects of the study are 300 nurses who use the Nursing Information System at least for 6 months or longer; data was collected from August 26th to September 1st, 2005. The collected data was analyzed on SPSS 12.0. Results: The results showed that there are noticeable differences in the degree of satisfaction among the users using the Nursing Information System depended on the subjects' marital status, working department, job title, types of computer training and other facts, such as individual's ability of using the system finding necessary references. Nursing records (including administration and prescription of medicine) was chosen to be the priority for the recognition of the Nursing Information System; for motivation on establishment of Nursing Information System was the efficiency of work; and for any problems or troubles with the Nursing Information System was the delayed work due to the system-suspension. Conclusion: The study implied that Nursing Information System have improved and effective Nursing practice.

• Research in Community and Public Health Nursing
• /
• v.26 no.4
• /
• pp.390-397
• /
• 2015

Purpose: The purpose of this study was to explore practice-based evidence for health promotion in vulnerable populations with hypertension in primary health care settings. Methods: Two methodological procedures were adopted for this triangulation study. In the first phase, the sample was obtained from the computerized clinical data repository of a community nursing center. A total of 286 clients were assessed for hypertension as an actual circulation problem as coded in the Omaha System. In the second phase, a qualitative focus group was surveyed through semi-structured interviews conducted by nine advanced practice nurses who had been serving the hypertensive patients. Results: The community nurses provided essential primary healthcare services including health teaching guidance and counseling, and surveillance to vulnerable populations living in medically underserved community. There was a significant positive correlation between knowledge and behavior (r=.53, p<.01), between knowledge and health status (r=.40, p<.05), and between behavior and health status (r=.48, p<.01). Conclusion: This triangulation study encompassed not only quantitative findings from the computerized records of clients but also other information acquired from advanced practice nurses. This study contributes to understanding the importance of health promotion nursing interventions even with populations already diagnosed with chronic diseases such as hypertension.

• Journal of Korean Academy of Nursing Administration
• /
• v.6 no.1
• /
• pp.55-81
• /
• 2000

This study examined nursing care in a Newborn Intensive Care Unit (NICU) by reviewing nursing activities for the newborns. Through direct observation, time used for nursing care according to the nursing activity, shift, day of the week, and position of the nurses was measured. This study was done on November 15, 21, 24, 1999 at a university medical center hospital and included eight nurses and 179 newborns as the study subjects. The data were collected from the medical records, and by using a nursing activity record for the NICU, and a nursing activity time record for the NICU. The first step in the data collection process was to develop a list of nursing activities which was done through a literature review, examination of medical affairs and duty records. Content validity was measured by a panel of three professors who were experienced clinicians. In the second step two pre-training sessions were held with three sophomore student nurses who then measured the time for each nursing activity using a stopwatch. The data were analyzed using frequencies for nursing activities, averages, percentages and ANOVA for differences between shift and between days of the week, and percentages and t-test for differences according to position of the nurse. The results are as follows: 1) The total number of activities was 156, direct or indirect nursing activities. Direct nursing activity classified according to physical, educational, emotional/social/economic/spiritual needs. There were 109 direct nursing activities in 16 fields. 2) The order of nursing activities, according to time required, was record keeping, nutritional care, measurement/observation, medication, hygiene care, examination and specimen collection, and checking supplies, and according to frequency, measurement/ examination, record keeping, nutrition care, hygiene care, elimination care and medication. 3) According to shift, direct care during the night shift at 313.4 minutes was the longest time and indirect nursing care during the night shift at 252.2 minutes was the highest time. 4) For days of the week, Monday had the highest time for direct care 275.8 minutes (34.6%) and Wednessday had the highest time for indirect nursing care 269.6 minutes (36.1%). 5) For nursing time according to position of nurse, general nurses had the highest for direct care (330.7 minutes), nurse managers for indirect nursing activities (239.0 minutes) and general nurses for individual private time (63.9 minutes). The results of this study show that the major nursing time consuming activities included record keeping, nutrition care and measurement/examination. For newborns, time needs to be allowed for care to be sensitive, sophisticated and specialized rather than concentrated on indirect nursing tasks such as record keeping. Therefore, it is imperative to develop computerized systems that support a systematic approach to record keeping which is more efficient. Moreover, nursing needs according to shift, day or position of nurse can be utilized in assessing nursing resources through a computerized process.

• Journal of Korean Academy of Fundamentals of Nursing
• /
• v.21 no.2
• /
• pp.151-161
• /
• 2014

Purpose: The purpose of this study was to identify the risk factors that influence surgical site infections after surgery. Methods: This study was a retrospective research utilizing Electronic Medical Records. Data collection targeted 4,510 adult patients who had 8 different kinds of surgery (gastric surgery, colon surgery, laparoscopic cholecystectomy, hip & knee replacement, hysterectomy, cesarean section, cardiac surgery) in 4 medical care departments, at one general hospital between January 2006 and December 2011. Multivariate logistic regression analyses were used to identify the risk factors affecting surgical site infections after surgery. Results: Risk factors for increased surgical site infection following surgery were confirmed to be age (OR=1.59, p<.001), BMI (Body Mass Index)(OR=1.25, p=.034), year of operation (OR=2.45, p<.001), length of operation (OR=3.06, p<.001), ASA (American Society of Anesthesiology) score (OR=1.36, p=.025), classification of antibiotic used (OR=2.77, p<.001), duration of the prophylactic antibiotics use (OR=1.85, p<.001), and interaction between classification of antibiotic used and duration of the prophylactic antibiotics use (OR=1.90, p=.016). Conclusions: Results suggest that risk factors affecting surgical site infections should be monitored before surgery. The results of this study should contribute to establishing effective infection management measures and implementing surveillance systems for patients who have actual risk factors.

• Journal of Korean Academy of Nursing Administration
• /
• v.8 no.3
• /
• pp.411-430
• /
• 2002

Purpose : This study was to develop Nursing Process Model of abdominal surgery patient using nursing diagnoses of NANDA, Nursing Interventions Classification(NIC), and Nursing Outcomes Classification(NOC). Method : The data in database were collected from nursing records in sixty patients with abdominal surgery admitted in a university hospital and open questionnaires of thirteen nurses. Systematic nursing process resulting from each nursing diagnoses, most common, was developed by the statistical analysis through database query from clinical database of abdominal surgery patients. Result : 51 nursing diagnoses were identified in abdominal surgery patients. The most commonly occurred nursing diagnoses were Pain, Risk for Infection, Sleep Pattern Disturbance, Hyperthermia, Altered Nutrition: Less Than Body Requirements in order. The linkage lists of NANDA to NIC and NANDA to NOC, and the nursing activities according to nursing diagnoses of abdominal surgery patients were identified in unit. Conclusion : Nursing Process of abdominal surgery patients was comprised of core nursing diagnoses, core nursing interventions, core nursing outcomes which provides the most reliable data in unit and could make nurses facilitate nursing process easily without full consideration of knowledge about nursing language classification system. Therefore, it could support nurses' decision making and recording of nursing process especially in the computerized patient record system if unit nursing process model using standardized nursing language system which contains of their own core nursing process data was developed.

• Journal of Intelligence and Information Systems
• /
• v.16 no.2
• /
• pp.73-94
• /
• 2010

The attending system is a medical system that allows doctors in clinics to use the extra equipment in hospitals-beds, laboratory, operating room, etc-for their patient's care under a contract between the doctors and hospitals. Therefore, the system is very beneficial in terms of the efficiency of the usage of medical resources. However, it is necessary to develop a strong support system to strengthen its weaknesses and supplement its merits. If doctors use hospital beds under the attending system of hospitals, they would be able to check a patient's condition often and provide them with nursing care services. However, the current attending system lacks delivery and assistance support. Thus, for the successful performance of the attending system, a networking system should be developed to facilitate communication between the doctors and nurses. In particular, the nursing records in the attending system could help doctors monitor the patient's condition and provision of nursing care services. A nursing record is the formal documentation associated with nursing care. It is merely a data repository that helps nurses to track their activities; nursing records thus represent a resource of primary information that can be reused. In order to maximize their usefulness, nursing records have been introduced as part of computerized patient records. However, nursing records are internal data that are not disclosed by hospitals. Moreover, the lack of standardization of the record list makes it difficult to share nursing records. Under the attending system, nurses would want to minimize the amount of effort they have to put in for the maintenance of additional records. Hence, they would try to maintain the current level of nursing records in the form of record lists and record attributes, while doctors would require more detailed and real-time information about their patients in order to monitor their condition. Therefore, this study developed a system for assisting in the maintenance and sharing of the nursing records under the attending system. In contrast to previous research on the functionality of computer-based nursing records, we have emphasized the practical usefulness of nursing records from the viewpoint of the actual implementation of the attending system. We suggested that nurses could design a nursing record dictionary for their convenience, and that doctors and nurses could confirm the definitions that they looked up in the dictionary through negotiations with intelligent agents. Such an agent-based system could facilitate networking among medical institutes. Multi-agent systems are a widely accepted paradigm for the distribution and sharing of computation workloads in the scientific community. Agent-based systems have been developed with differences in functional cooperation, coordination, and negotiation. To increase such communication, a framework for a multi-agent based system is proposed in this study. The agent-based approach is useful for developing a system that promotes trade-offs between transactions involving multiple attributes. A brief summary of our contributions follows. First, we propose an efficient and accurate utility representation and acquisition mechanism based on a preference scale while minimizing user interactions with the agent. Trade-offs between various transaction attributes can also be easily computed. Second, by providing a multi-attribute negotiation framework based on the attribute utility evaluation mechanism, we allow both the doctors in charge and nurses to negotiate over various transaction attributes in the nursing record lists that are defined by the latter. Third, we have designed the architecture of the nursing record management server and a system of agents that provides support to the doctors and nurses with regard to the framework and mechanisms proposed above. A formal protocol has also been developed to create and control the communication required for negotiations. We verified the realization of the system by developing a web-based prototype. The system was implemented using ASP and IIS5.1.

• Journal of Korean Clinical Nursing Research
• /
• v.21 no.3
• /
• pp.377-388
• /
• 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.

• Journal of Korean Academy of Nursing
• /
• v.20 no.3
• /
• pp.368-380
• /
• 1990

A central issue in the development of nursing practice is to describe the phenomenon with which nursing is concerned. To identify the health problems which can be diagnosed and managed by the nurse is the first step to organize and ensure the development of nursing science. Therefore the academic world has been discussing the application of the nursing diagnosis in nursing practice as a means of improving quality of care. The objectives of this study were to develop a standardized nursing care plan for ten selected nursing diagnoses to form a database for computerized nursing service. The research approach used in the study was (1) the selection of the ten nursing diagnoses which occur most frequently on medical-surgical wards, (2) the development of a standardized nursing care plan for the ten selected nursing diagnoses, (3) application of the plan to hospitalize patients and evaluation of the content validity by the nurses, and (4) evaluation of the clinical effects after the use of the standardized nursing care plans. The subjects were 56 nurses and 395 hospitalized patients on two medical and two surgical unit. The results of this study were as follows ; 1) The ten selected nursing diagnoses for the development of the standardized nursing care plans were “PAIN, SLEEP DISTURBANCE, ALTERED HEALTH MAINTENANCE, ALTERATION IN NUTRITION, ANXIETY, CONSTIPATION, ALTERED PATTERNS OF URINARY ELIMINATION, DISTURBANCE IN BODY IMAGE, POTENTIAL FOR ACTIVITY INTOLERANCE AND ACTIVITY INTOLERANCE”. 2. The developed standardized nursing care plans included the nursing diagnosis, definition, defining characteristics, etiologic or related factors that contribute to the condition, recording pattern, desired outcomes and nursing orders (nursing interventions). 3. The plan was used with hospitalized patients on medical - surgical wards to test for content validity. The patient's satisfaction with the nursing care and nurses' job satisfaction were investigated to evaluate the clinical effects after the use of the standardized nursing care plans. A comparison of patient satisfaction with nursing care before and after the introduction of the standardized nursing care plans showed a statistically significant higher level of satisfaction with the standardized care plans. There was no difference in the level of job satisfaction expressed by the nursing staff before and after the standardized nursing care plans were introduced. However, when opinions about the use of the standardized nursing care plans were examined it was found that there was a positive effect on clarity in defining the nursing problems, determining nursing cost, more feasible goal setting, effective and systematic nursing records and indications for nursing research. The results of this study suggest that in order to increase the use of nursing diagnoses in the clinical area, it would be effective to select some wards as a pilot project, give the nurses training in the use of nursing diagnosis and develop and use the standardized nursing care plans. In addition to the ten diagnosis used in this study it is recommended that continual development of nursing diagnoses be done using diagnoses that are appropriate to Korea and testing them for validity through standardized care plans.