• 제목/요약/키워드: Nursing Records

검색결과 576건 처리시간 0.027초

간호정보시스템에 대한 사용자 만족도 (Users' Satisfaction with Nursing Information System)

  • 김소연
    • 간호행정학회지
    • /
    • 제12권4호
    • /
    • 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.

  • PDF

우리나라 대도시 보건소 방문간호 사업유형별 방문간호원가 및 소요재정 추계 분석 (Estimating the Cost of Visiting Nursing Service by Visiting Nursing Model for Urban Public Health Center in Korea)

  • 유호신
    • 대한간호학회지
    • /
    • 제34권6호
    • /
    • pp.983-993
    • /
    • 2004
  • Purpose: This study focused on analysing costs per visiting nursing care based on nursing activities in a public health center. Method: The Easley-Storfjell Instrument(1997) was used for a prospective descriptive analysis of self-records for workload data from 10 visiting nurses during 4 weeks on all nursing activities. In addition, analysis of the 478 visiting nursing records and cost data from 5 home visiting departments in public health centers during one year of 2003 was done. Result: The workload of visiting nurses by the type of model was identified as follows: Type I showed that caseloads made up 32.9 % of all nurse activities, and type II showed that the caseloads made up 45.8 %. Second, The cost per visit in type I was 33,088 won and 31,323 won in type II. Third, the estimated budgets were 1,902,436 won to 12,057,696 won for the type I model. and 4,151,316 won to 17,432,712 won for the type II model for one year. Conclusion: This study's results will contribute to baseline data used to establish on infrastructure for visiting nursing program and visiting nursing agencies based on the budget of visiting nursing services.

전산화된 표준간호서식 프로그램 개발에 관한 연구;일 대학병원 중심으로 (A Study on the Development of Computerized Program for the Standardized Nursing Documentation Form;Based on A University Hospital)

  • 이소정;최경숙
    • 간호행정학회지
    • /
    • 제11권3호
    • /
    • 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.

  • PDF

통증 간호사정을 위한 임상내용모델 개발 (Development of Detailed Clinical Models for Pain Assessment)

  • 민열하;박현애;이영지;김영란;이명경
    • Perspectives in Nursing Science
    • /
    • 제8권2호
    • /
    • pp.113-120
    • /
    • 2011
  • Purpose: The aim of this study was to develop and validate Detailed Clinical Models (DCMs) for pain assessment in nursing. Methods: First, we identified the entities of pain assessment from ICNP. We identified the attributes and values of the attributes to describe the entities in more detail by reviewing the literature. Data types and optionalities of the attributes were defined. Second, we modeled the DCMs by linking an entity and its corresponding attributes with values and by specifying the data types and optionalities of the attributes. Finally, the DCMs were validated by a group of domain experts using a content validity index. Results: In total, 19 DCMs with 11 attributes for pain assessment were developed. The experts' evaluations showed that the DCMs were valid enough to represent pain related information of nursing assessment. Conclusion: The DCMs developed in this study can be used in electronic nursing records. The DCMs for pain can ensure the semantic interoperability of pain related information in electronic nursing records.

  • PDF

가정간호 기록지 분석 - 원주기독병원 가정간호 보건활동을 중심으로 - (An Analysis of Referrals, Nursing Diagnosis, and Nursing Interventions in Home Care - Wonju Christian Hospital Community Health Nursing Service -)

  • 서미혜;허혜경
    • 가정∙방문간호학회지
    • /
    • 제3권
    • /
    • pp.53-66
    • /
    • 1996
  • Home Health Care is one part of the total health care system. It includes health care services that link the hospital to the community. While it is important for early discharge patients, home care is also important for people with chronic illnesses or handicapping conditions. In 1989 the Korean government passed a law that opened the way for formal development of home health care services beginning with education programs to certify nurses for home care, and then demonstration home care services. Part of the mandate of the demonstration projects was evaluation of home care services. This study was done in order to provide basic data that would contribute to the development of records that could be used for evaluation through a retrospective audit and to examine the care that had been given in Home Care at Wonju Christian Hospital over a twenty year period from 1974 to 1994. The purposes of the study were : to identify to characteristics of the clients who had received home care, to identify the reasons for client referrals, to identify the nursing problems of these clients, to identify the nursing care provided to these clients, and to identify differences in these areas over the twenty year period. The study was a descriptive study involving a retrospective audit of the client records. Demographic data on all clients were included : 4,171 clients from 2,564 families. Data on referrals, nursing diagnosis and nursing interventions were from even numbered records which had a patient problem list included in the record, 2,801 clients, Frequencies and ANOVA were used in the analysis. The results of the study showed that the majority of the clients were from Wonju city /county. There were more women than men related to the high number of postpartum clients(1,300). The high number of postparttum clients and newborns was also evident in the age distribution. An the number of maternal-child clients decreased over the 20 years, the mean age of the clients increased significantly. Other factors also contributed to this change ; as increasing number of clients with brain injuries or with cancer, and fewer children with burns, osteomyelitis and tuberculosis. There was a decrease in the mean number of visits and mean length of coverage, reflecting a movement towards a short term acute care model. The number of new clents dropped sharply after 1985. The reasons for this are : the development of other treatment alternatives for clients, the establishment of an active wellbaby clinic, many more options plus a decreasing number of new cases of Hansen's Disase, and insurance that allows people with burns to be kept in hospital until skin grafts are healed. Socioeconomic changes have resulted in an increase in the number of cases of cancer, stroke, head injuries following car accidents, and of diabetes. Of the 2,801 client records, 2,541(60.9%) contained a written referral but for 1,802 it contained only the medical diagnosis. The number of records with a referral requesting specific nursing care was 739(29.1%). Many family members who were identified as in need of nursing care had no written referral. Analysis of the patient problem list showed that 41.9% of the enteries were nursing diagnoses. Others incuded medical diagnosis, symptoms, and plans. The most frequently used diagnoses were alteration in nutrition, less than body requirements(115 entries), alteration in skin integrity(114), knowledge deficit(111), pain(78), self-care deficit(66), and alteration in pattern of urinary elimination(50). These are reflected in the NANDA categories for which the highest number of diagnosis was in the Exchanging pattern(446), followed by Moving(178), Feeling(136) and Knowing (115). Analysis of the frequency of interventions showed that exercise and teaching about exercise was the most frequent intervention, followed by teaching concering the need for follow-up care, checking vital signs, managing nutritional problems, managing catheters, giving emotional support, changing dressings, teaching about medication, teaching (subject not specified), teaching about diet, IM and IV medications or fluid, and skin care, in that order. Recommendations included: development of a record that would allow for efficient recording of frequently used nursing diagnoses and nursing interventions: expansion of the catchment area for Home Care at Wonju Christian Hospital ; expansion of the service to provide complication prevention, rehabilitation services, and support to increase the health maintenance /health promotion of the people being served as well as providing client dentered care ; and development of a clinical record that will allow efficient data collection from records, even though the recording is done by a variety of health care providers.

  • PDF

Evaluation of Nursing Documentation of Delirium Care

  • KANG, Yun
    • International Journal of Advanced Culture Technology
    • /
    • 제7권1호
    • /
    • pp.112-121
    • /
    • 2019
  • The purpose of the study was to determine whether a delirium educational program has a positive outcome on nurses' documentation in patient records of delirium care. A one group pre-post design was used. A convenient sample of 60 consecutive records that included documentation by participating nurses in four medical wards of one regional general hospital in South Korea was audited two months before and two months after a delirium educational program. Although an educational program in this study positively changed nurses' knowledge and attitudes, these positive effects did not translate to improvement in the documentations of delirium care. There was no significant increase in the frequency of nursing documentation of delirium assessment following participation in the educational program. Furthermore, there was no significant increase in the frequency of nursing documentation of the use of non-pharmacological management following the documentation of keywords associated with delirium after participation in the educational program. The findings indicate the need to develop, implement and record a systematic risk assessment for delirium and assessment and management of existing delirium based on evidence-based guidelines in clinical practice in South Korea.

뇌졸중의 신경학적 사정 도구인 NIHSS 적용을 위한 체계적인 간호사 교육 프로그램의 효과 (Effect of Systematic Educational Program for the Application of National Institutes of Health Stroke Scale (NIHSS) as a Neurologic Assessment Tool in Stroke Patients)

  • 한정희;이지은;안영희;유성희
    • 임상간호연구
    • /
    • 제19권1호
    • /
    • pp.57-68
    • /
    • 2013
  • Purpose: In assessing patients' neurological status following a stroke it is very important to have a valid tool for early detection of neurological deterioration. NIHSS is considered the best tool to reflect neurological status in patients with ischemic stroke. An education program on use of NIHSS was planned for nurses caring for these patients and the effects of the program were evaluated. Methods: The NIHSS education program (NEP) which includes online and video lectures, and practical education was provided to the nurses from April to July, 2010. To examine the effect of NEP, nursing records of patients with ischemic stroke who were admitted to a stroke center were analyzed. Two groups, a historical control group (n=100) and the study group (n=115) were included. Results: Nursing records for neurologic symptoms for each patient increased (41.0% versus 100.0%, p<.001), and especially, visual disturbance, facial palsy. limb paralysis and ataxia, language disturbance, dysarthria, and neglect symptoms significantly increased (all p<.001). Nurse notification to the doctor of patients with neurological changes increased (21.0% versus 39.1%, p=.004), and nurses' neurological deterioration detection rates also increased (37.5% versus 84.6%, p=.009). Conclusion: NEP improved the quality of nursing records for neurological assessment and the detection rate of neurological deterioration.

산부인과 간호단위의 간호과정과 SNOMED CT를 이용한 간호진단 온톨로지의 구축 (Construction of the Nursing Diagnosis Ontology in Obstetric and Gynecologic Nursing Unit using Nursing Process and SNOMED CT)

  • 박정은;정귀애;조훈;김화선
    • 여성건강간호학회지
    • /
    • 제19권1호
    • /
    • pp.1-12
    • /
    • 2013
  • Purpose: This study was performed to propose an ontology methodology based on standardized nursing process as framework in obstetric and gynecologic nursing practice. Methods: The instrument used in this study was based on the nursing diagnosis classification established by North American Nursing Diagnosis Association (NANDA) (2009-2011), fifth edition of the Nursing Interventions Classification (NIC) (2008), forth edition of the Nursing Outcomes Classification (NOC) (2008) developed by Iowa State University and systematized nomenclature of medicine clinical terms (SNOMED CT). The nursing records data were collected from electronic medical records of one hospital from August to October 2010. Results: One hundred and forty-one nursing diagnosis statements used in obstetric and gynecologic nursing unit were linked standardized nursing classifications and constructed nursing diagnosis ontology including interoperability. Conclusion: Not only will this result be helpful to complete nurse's lack of knowledge and experience, it will also help to determine nursing diagnosis logically by using standardized nursing process. It will be utilized as the method to construct ontology including interoperability in other nursing units. It will be presented nursing interventions according to nursing diagnosis and thus will be easier to establish nursing planning. This can provide immediate feedback of the nursing process application.

일 지역 중국인 유학생의 영양소 섭취 상태, 체질량지수와 우울의 관계 (Nutritional Intake, Body Mass Index and Depression Among Chinese College Students in an Urban Area of South Korea)

  • 진정;서민희
    • Journal of Korean Biological Nursing Science
    • /
    • 제22권2호
    • /
    • pp.81-89
    • /
    • 2020
  • Purpose: The purpose of this study was to investigate nutritional intake, body mass index (BMI) and depression, and to elucidate depression in relation to nutritional intake and BMI among Chinese college students studying in South Korea. Methods: A descriptive study design was adopted. Data were collected from 170 Chinese college students in South Korea June-August, 2019. In this study, 24-hour dietary records were obtained and BMI was measured. Nutrient intakes were calculated from the dietary records using the CAN-PRO software. Depression was assessed using the Center for Epidemiological Studies Depression Scale (CES-D). Results: Of 170 participants, 19 (11.2%) were underweight and 42 (24.7%) were overweight. Female, single, and non-smoking participants were underweight. There were 97 (57.1%) participants experiencing depression, and 99 (58.2%) consuming lower protein than the recommended nutrient intake resulting in insufficient nutrients. The intake of vitamin A, vitamin C, vitamin D, pantothenic acid, calcium, iron, and selenium was much lower than the standard. Depressive participants were significantly greater among the underweight participants and those consuming insufficient nutrients in terms of protein, pantothenic acid, and selenium. Conclusion: An intervention program is required to improve nutritional status, which should be a part of the strategies to manage depression for Chinese college students in South Korea.

일개 병원에서의 환자간호 평가도구 사용이 간호사들의 업무수행정도와 직무만족에 미치는 영향 (The Effect of Using a Nursing Care Scale Influencing on The Nursing Performance and Job Satisfaction)

  • 박인숙;박성애
    • 간호행정학회지
    • /
    • 제1권1호
    • /
    • pp.65-78
    • /
    • 1995
  • This is a quasi-experimental research to test the effect of using a nursing care scale. This study identified the effects of using a nursing care scale influencing on the nursing performance and job satisfaction. The subjects consisted of 63 staff nurses in 8 medical and surgical units of one hospital affiliated to university hospital in Seoul, and assigned to experimental and control group conveniently. The data were collected in September and December, 1992. The evaluation of the nursing performance were measured by the instrument from a nursing care scale of one univerrsity hospital and job satisfaction was measured by Stamp's Scale (1978). The data were analyzed by percentage distribution, 2-test, Mann-Whitney U Wilcoxon Rank Sum W test, ANCOVA and T-test. The summarized results were as follows : 1. The nursing performance of the experimental group showed markedly increase about 13 areas of nursing care. However no significant difference in the nursing performance between the two groups was found. 2. There was a significant difference in the nursing performance between the experimental and the control group about 7 areas of nursing records(W=22.0, P<.05). 3. After using a nursing scale, there was a significant difference in the nursing performance about nursing care and nursing records between the experimental and the control group(W=25.0, P<.05). Comparing before using a nursing scale with after, there was no significant difference in the nursing performance between two groups. 4. There was no significant difference in job satisfaction between the experimental and the control group. The main reasons for there being no defference in two groups could be the small size sample and the procedure of intervention. Further comparative study is needed using more strictly controlled procedure of intervention.

  • PDF