• 임상간호연구
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• 제19권3호
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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.

• 가정간호학회지
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• 제27권1호
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• pp.102-113
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• 2020

Purpose: To demonstrate the importance of comprehensive skin observation as an effective intervention for pressure injury prevention in elderly long-term care hospital patients. Methods: The survey was conducted with 70 nursing staff members working at two long-term care hospitals with 200 beds or less in D city. Data were collected from October 16 to October 23, 2019 and analyzed using descriptive statistics, the chi-square test, and the independent t-test with the SPSS 25.0 program. Results: Nursing care knowledge for pressure injury was similar between the two groups. Conversely, nursing care performance for pressure injury degree of the nursing staff in the hospital using skin observation records performed better than those who did not (t=6.11, p<.001). Furthermore, comprehensive skin assessments in long-term care hospitals using skin observation records showed a lower incidence rate of pressure injury than that showed using general skin assessments (t=-5.28, p=.006). Conclusions: Comprehensive skin assessment is important for pressure injury prevention in elderly long-term care hospital patients. To implement this effectively, it is necessary to devise institutional regulations, guidelines, and systematic education programs.

• 대한간호학회지
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• 제37권6호
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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.

• 여성건강간호학회지
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• 제22권3호
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• pp.170-181
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• 2016

Purpose: The aim of this study was to identify the nursing diagnosis-outcome-intervention (NANDA-NOC-NIC) linkages for gynecology inpatients shown in their electronic nursing records. Methods: This retrospective and descriptive research was conducted in two steps and based on the 287 electronic nursing records for 253 patients. First, nursing diagnoses, outcomes and interventions were collected. To identify major nursing diagnoses, a comparison was done with the top 10 nursing diagnoses from this research and with previous research selected using a content validity index developed by a team of professionals. Second, nursing outcomes and interventions that were associated with major nursing diagnoses were identified. Results: Nineteen nursing diagnoses, 12 nursing outcomes, and 40 nursing interventions were collected. The top 5 major nursing diagnoses were identified and 7 nursing outcomes and 18 nursing interventions associated with these diagnoses were checked. Conclusion: The identified NANDA-NOC-NIC linkages can contribute to improving nursing practice and will help in the establishment of standardized nursing care.

• 기본간호학회지
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• 제26권1호
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• pp.32-41
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• 2019

Purpose: The purpose of this study was to identify the risk factors for postoperative pulmonary complications (PPCs) after upper or lower abdominal digestive tract surgery. Methods: Participants in this retrospective observational study had undergone upper or lower digestive tract surgery and entered the surgical intensive care unit between March 1, 2016 and February 28, 2017. Data were collected from the medical records, operative records, results of laboratory test, and the nursing records of the hospitals. Results: Of the patients, 544 patients were enrolled in the study and PPCs -developed in 335 (61.6%) patients. On multivariate logistic regression analysis, significant risk factors of PPCs were identified: BMI (Body Mass Index; $kg/m^2$), preoperative serum BUN (Blood Urea Nitrogen; mg/dL), abdominal open surgery, or blood transfusion during operation. Conclusion: These risk factors could be used to help identify patients at risk for PPCs and then appropriate nursing interventions could be provided for patients at risk of PPCs.

• 대한간호학회지
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• 제45권4호
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• pp.523-532
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• 2015

Purpose: The usability, user satisfaction, and impact of electronic nursing record (ENR) systems were investigated. Methods: This mixed-method research was performed as a time-motion (TM) study and a survey which were carried out at six hospitals between August and November 2013. The TM study involved 108 nurses from medical, surgical, and intensive care units at each hospital, plus an additional 48 nurses who served as nonparticipating observers. In the survey, 1879 volunteer nurses completed the Impact of ENR Systems Scale, the System Usability Scale, and a global satisfaction scale. Qualitative and quantitative analyses were performed. Results: The mean scores for the ENR impact, system usability, and satisfaction were 4.28 (out of 6), 58.62 (out of 100), and 74.31 (out of 100), respectively, and they differed significantly between hospitals (F=43.43, p<.001, F=53.08 and p<.001, and F=29.13 and p<.001, respectively). A workflow fragmentation assessment revealed different patterns of ENR system use among the included hospitals. Three user characteristics-educational background, practice period, and experience of using paper records-significantly affected the system usability and satisfaction scores. Conclusion: The system quality varied widely among the ENR systems. The generally low-to-moderate levels of system usability and user satisfaction suggest many opportunities for improvement.

• 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.

• 지역사회간호학회지
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• 제9권2호
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• pp.303-312
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• 1998

The purpose of this study was to survey the knowledge level, attitude and practice of nurses toward their work. The subjects of the study were composed of 98 nurses from 3 general hospitals, 1 oriental medical hospital, 2 health centers and several community health posts and schools. Data were collected from May to October, 1998. In data analysis, an SPSS PC program was utilized for descriptions. 1) 16 nurses (16.3%) experienced medical accidents on the 7 nurses(7.1%) 1 time, 6 nurses (6.1%) 2 times, and 3 nurses(3.1%) 3 times. 2) Concerning knowledge of their legal obligations ; the prohibition of telling secrets was .89, the prohibition of reading medical records was .58, the keeping of medical records was 1.0 and the teaching of recuperation was. 79. The total mean score was. 86. Concerning attitude and practice; the prohibition of telling secrets was 81.6%, 63.3%. The prohibition of reading medical records was 61.2%, 60.2%. The keeping of medical records was 98%, 98%. The explanation for treatment, care and test was 91.8%, 66.3%. The teaching for recuperation was 63.3%, 63.3%. 3) Knowledge of their legal responsibilities; 29. 6% of the subjects thought that they should report a medical accident to their headnurse, but 75.5% of the subjects actually reported to the headnurse. 39.8% of the subjects thought that nurses were liable for the faults of nursing aides. The total mean score was .45. 46% of the subjects asked a senior staff's advide on difficult affairs. Nurses obeyed legal obligations when concern ing the protection of a client, but were passive when concerning self protection. Also, headnurses were required as adviser, guide and advocate.

• 한국간호교육학회지
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• 제27권2호
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• pp.152-162
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• 2021

Purpose: The purpose of this study was to examine the effect of nursing record education on the knowledge and performance of nursing record of nurses at small- and medium-sized hospitals. Methods: The participants were 62 nurses working in two small- and medium-sized hospitals. Thirty-two nurses comprised the experimental group, and 30 nurses comprised the control group. Nursing record education was provided for the experimental group. Data were analyzed by x²-test and t-test analysis using the IBM SPSS statistics 25.0 Program. Results: After education, the knowledge (t=2.43, p=.019), performance (t=2.19, p=.033) and behavior scores (t=2.42, p=.018) on nursing record were significantly higher in the experimental group than in the control group. Based on this result, nursing record education is an effective intervention to improve nurses' knowledge and performance in writing nursing records in small- and medium-sized hospitals. Conclusion: We suggest the development of a systematic and standardized education program on nursing record including its legal aspects, for nurses in small- and medium-sized hospitals. The results of this study can be used as basic data for developing a nursing record education program for small- and medium-sized hospitals.

• 한국농촌간호학회지
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• 제15권2호
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• pp.66-73
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• 2020

Purpose: This study was done to report nursing case for ADL improvement of elders who have CVA(Cerebrovascular Accident) sequelae. Methods: The client had registered in the C visiting nursing center after being decided a long-term care Grade 2. Data were collected through consultation logs for recipients, Activities of Daily Living (ADL) records, fall risk assessment (Huhn) sheets, decubitus ulcer risk assessment (Braden Scale) sheets, cognition assessment (K-MMSE) sheets, long-term care benefit provision records, and interviews with visiting nurse. Data were collected and analyzed according to the Omaha System problem classification. The intervention scheme and the problem rating scale for performance were applied to present the case for home-visit nursing. Results: The client registered in August, 2018, was provided home-visit nursing care once a week as of September 2020. ADL, cognitive levels and decubitus ulcer risks were found to have improved. Conclusion: This case report presents the value of classifying nursing problems and checking nursing intervention provided to patients with problems of ADL. The presentation of home-visit nursing cases applying a standardized nursing problem classification scheme for clients with various problems showed that a high quality level of care is guaranteed and evidence-based nursing can be provided by visiting nurses.