• 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.

• 가정∙방문간호학회지
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• 제11권1호
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• pp.14-22
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• 2004

The purpose of this study was to establish the basic-data set for the electronic nursing records system by analysis of nursing phenomenas and nursing actions described in nursing records of orthopedic patients using the ICNP. Nursing notes for 1.421 days of 97 orthopedics patients who were discharged from a tertiary teaching hospital in Daegu were used. Narrative data from the nursing notes were collected. decomposed. and cross mapped with the concepts of the ICNP beta version. In total 11.442 statements were found in the process of decomposing the narrative data into single statement. These statements consist of 3.970(34.70%) nursing phenomena statements. 6.996(61.14%) nursing action statements, and 476(4.16%) other statements. Finally 312 unique statements were collected by integrating same or similar statements. These statements consist of 120 (38.46%) nursing phenomena statements. 154 (49.36%) nursing action statements. and 38 (12.18%) other statements. When this result was cross mapped with ICNP beta version. 77.0% of nursing statements were completely expressed. 17.0% of them were partially expressed. and 0.3% of them were not able to expressed at all. The findings of this study showed the usability of ICNP as terminology of electronic nursing records system. And the result of this study can be utilized for an ICNP-based electronic nursing records system and can help clinical nurses to spend more time on direct nursing.

• 한국병원경영학회지
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• 제15권1호
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• pp.1-12
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• 2010

This study was tried to evaluate the level of completeness and the accordance in electronic medical records by comparing paper-based medical record in doctor's admission records, discharge summary, and nursing information records. Medical records of inpatients of neurology department that the 100 paper-based medical records in 2004 and 100 electronic medical records in 2006 were targeted. Existence of record items and doctor-nurse record accordance were evaluated in doctor's admission record, discharge summary, admission nursing information record, and discharge nursing information record. There were not any differences between electronic medical records and paper-based medical records in doctor's admission record and discharge summary. Electronic medical records had less missing records than paper-based medical records in admission and discharge nursing information records. Electronic medical records showed higher accordance than the paper-based medical record in doctor-nurse record generally, but there were statistically differences in only medication, allergy, smoking, and drinking (p<0.05). In this study, it was verified that the quality of electronic medical records are better than paper-based records in nursing information record and doctor-nurse record agreement.

• 성인간호학회지
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• 제18권4호
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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.

• 성인간호학회지
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• 제14권2호
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• pp.165-173
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• 2002

Purpose: this study is to explore how useful ICNP nursing phenomena and actions classification is to describe the nursing problem and nursing action statements of nursing records. Method: The number of nursing phenomena statements found in this research were 323. Out of these 323, 222 statements can be fully classified, 62 statements can be partially classified, and 39 statements can not be classified at all by terms from the ICNP phenomena classification axis. Result: The number of nursing practice statements were 318, 252 of which can be fully classified, 63 statements can be partially classified, 3 statements cannot be classified at all by terms from the ICNP nursing action classification axis. Conclusions: In order to describe all the statements found in nursing records, not only new terms but also new axis need to be added to the ICNP.

• Perspectives in Nursing Science
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• 제5권1호
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• pp.33-43
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• 2008

Objective: This study explored the reuse of data captured into an electronic nursing record system using the International Classification for Nursing Practice to support nursing research of inpatient's falls. Methods: Risk factors relevant to inpatients falls ;n an acute setting were identified from the literature review. Four risk assessment tools and two risk identification studies were selected. To examine the availability of coded data in an electronic nursing record system for the identified fall fisk factors, we reviewed 11.319 hospital-day records of 118 patients who were reported by the self-report system. Results: We identified 24 fall risk factors of five categories from the literature review, which were used to identify the standard nursing statements addressing fall risks. One hundred thirty five nursing statements were searched from the hospital's nursing data dictionary of statements and were matched with 14 fall fisk factors. Using the 135 statements. we found that mental status, catheter of drip in situ, abnormal gait, insomnia, surgical procedure. and dizziness/vertigo appeared frequently in the nursing records of inpatients with fall s. Also we found 6 risk factors more through the record review. Conclusion: The electronic records would be a good research source for inpatients' falls. Specifically international classification for nursing practice based nursing record system has the potential for promoting clinical researches.

• 간호행정학회지
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• 제10권2호
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• pp.243-254
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• 2004

Purpose: The purpose of this study was cross-mapping unique nursing statements which were identified in the nursing records of patients with six most common cancers in Korea with the standardized nursing languages of NANDA, NIC, NOC and ICNP. Method: The subjects were 72 nursing records which covered 1,502 admission days from August 1, 2003 to June 30, 2003. They were the records of the patients of six most common cancers who were treated at the six 3rd level general hospitals in Busan and Daegu. The unique nursing statements were identified by dividing the statements from the nursing records into the single statements according to their meanings. For cross-mapping, identified unique nursing statements were classified as 'Data(D)' for the subjective, objective data of the patients and the other data such as treatment, admission, discharge, and residence of patient, 'Problem(P)' for nursing problem or diagnosis defined by the nurse's decision, 'Intervention(I)' for nursing intervention for problem solving, and 'Outcome(O)' for patient reaction and results of the provided nursing interventions. Unique nursing statements classified to D, P, I, O were cross-napped by using Microsoft Excel 2000. The statements of D were cross-mapped with ICNP Nursing phenomena, P with NANDA nursing diagnosis and ICNP nursing phenomena, I with NIC and ICNP nursing intervention, and O with NOC and ICNP nursing phenomena Result: The results of this study were as follows. 1. Number of unique nursing statements were 506 in the records of lung cancer patients (18.12%), 480 in stomach cancer(17.19%), 458 in liver cancer(16.40%), 456 in colon cancer (16.33), 457 in breast cancer (16.36%) and 436 in cervix cancer (15.60%). 2. The range of percentage of cross-mapped unique nursing statements with the standardized nursing languages were as follows: P with NANDA nursing diagnosis $87.50{\sim}100%$, I with NIC $59.72{\sim}74.43$, O with NOC $61.05{\sim}72.64%$, and D, P, I and O with ICNP $60.92{\sim}69.95%$. 3. Number of the standardized nursing languages identified in this study were 21(12.66%) from 155 NANDA nursing diagnosis, 76(15.64%) from 486 NIC Nursing interventions, 54(17.47%) from 260 NOC nursing outcomes, and 343(13.03%) from ICNP 2,634. Conclusions: By the results of this study, NANDA, NIC, NOC and ICNP were found that they can be used as the language systems for nursing record and nursing information system for cancer patients. But, further study on the unique nursing statements which were not cross-mapped with the standardized nursing language systems will be necessary.

• 지역사회간호학회지
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• 제20권1호
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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.

• 지능정보연구
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• 제16권2호
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• pp.73-94
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• 2010

개방병원에 환자의 입원을 의뢰한 담당 의사들은 환자들의 상태와 제대로 된 간호서비스를 받고 있는지에 대한 정보를 간호기록을 열람함으로써 확인할 수 있다. 하지만 간호기록은 병원의 내부자료로써 외부기관에 쉽게 공개할 수 없는 자료이고 표준화가 확립되어 있지 않아 병원별로 다르게 작성되고 있어 필요한 정보를 공유하는데 많은 어려움이 따른다. 따라서 본 연구에서는 개방병원 간호기록의 작성과 공유를 지원하기 위한 시스템을 개발하고자 하였다. 본 시스템은 우선 간호기록을 실제로 작성하는 간호사의 편의성을 고려하여 간호기록항목사전을 설정하게 하고 간호사와 의사간의 지능형 에이전트를 이용한 협상으로 작성과 공개의 항목을 확정하도록 하였다. 이 모든 과정은 의료기관간의 네트워킹을 지원할 수 있도록 웹기반시스템으로 설계되었고 실제 구현을 통하여 실현가능성을 확인하였다.

• 임상간호연구
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• 제15권3호
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• pp.107-116
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• 2009

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.