Implementation of transoperative and immediate postoperative nursing diagnoses in the computerized management system / Implementación de diagnósticos de enfermería intraoperatorios y postoperatorios inmediatos en el sistema de gestión informatizado / Implementação dos diagnósticos de enfermagem do transoperatório e pós-operatório imediato no sistema de gestão informatizado

ABSTRACT Objective: To implement, on health management software, electronic records of the perioperative nursing process and the stages of transoperative and immediate postoperative nursing diagnoses, based on the NANDA International taxonomy. Method: Experience report conducted from the completion of the Plan-Do-Study-Act cycle, which allows improvement planning with a clearer purpose, directing each stage. This study was carried out in a hospital complex in southern Brazil, using the software Tasy/Philips Healthcare. Results: For the inclusion of nursing diagnoses, three cycles were completed, predictions of expected results were established, and tasks were assigned, defining "who, what, when, and where". The structured model covered seven possibilities of aspects, 92 symptoms and signs to be evaluated, and 15 nursing diagnoses to be used in the transoperative and immediate postoperative periods. Conclusion: The study allowed implementing electronic records of the perioperative nursing process on health management software, including transoperative and immediate postoperative nursing diagnoses, as well as nursing care.

RESUMEN Objetivo: Implementar, en un software de manejo de la salud, registros electrónicos del proceso de enfermería perioperatorio y la etapa de diagnósticos de enfermería transoperatorios y postoperatorios inmediatos, con base en la taxonomía NANDA internacional. Método: Informe de experiencia realizado a partir de la consecución del ciclo Plan-Do-Study-Act), que permite planificar la mejora con un propósito más claro, dirigiendo cada etapa. Este estudio fue realizado en un complejo hospitalario en el sur de Brasil, utilizando el Software Tasy/Philips Healthcare. Resultados: Para la inclusión de diagnósticos de enfermería, se concluíran tres ciclos, se estableceran predicciones de los resultados esperados, y se asignaron tareas, definiendo "quién, qué, cuándo y dónde". El modelo estructurado contempló siete posibles aspectos, 92 signos y síntomas para ser evaluados y 15 diagnósticos de enfermería para ser utilizados en el transperatorio y postoperatorio inmediato. Conclusión: El estudio permitió implementar, en un software de manejo de la salud, registros electrónicos del proceso de enfermería perioperatorio, que comprende diagnósticos de enfermería transoperatoria y postoperatoria inmediata, además de los cuidados de enfermería.

RESUMO Objetivo: Implementar, em um software de gestão em saúde, os registros eletrônicos do processo de enfermagem perioperatório e a etapa de diagnósticos de enfermagem transoperatório e pós-operatório imediato, fundamentados na taxonomia NANDA International. Método: Relato de experiência conduzido a partir da realização do ciclo PDSA (Plan-Do-Study-Act), o qual permite o planejamento de melhoria com um propósito mais claro, direcionando cada etapa. Este estudo foi realizado em um complexo hospitalar da região sul do Brasil, utilizando o software Tasy/Philips Healthcare. Resultados: Para a inclusão dos diagnósticos de enfermagem, rodaram-se três ciclos, estabeleceram-se previsões de resultados esperados, e as tarefas foram atribuídas, definindo "quem, o quê, quando e onde". O modelo estruturado contemplou sete possibilidades de aspectos, 92 sinais e sintomas a serem avaliados e 15 diagnósticos de enfermagem para serem utilizados no transoperatório e pós-operatório imediato. Conclusão: O estudo possibilitou implementar, em um software de gestão em saúde, os registros eletrônicos do processo de enfermagem perioperatório, compreendendo diagnósticos de enfermagem do transoperatório e pós-operatório imediato, além de cuidados de enfermagem.

A comparative analysis of the Omaha system applied to the nursing description of patients with coronary heart disease / 中国实用护理杂志

Objective@#To explore the feasibility of applying Omaha system theory to patients with coronary heart disease (CHD) through comparative analysis of nursing description.@*Methods@#Using content extraction analysis method, the nursing records, nursing plans and nursing measures of discharged patients with CHD were retrieved from the medical records, and then the conceptual consistency of the extracted records and the problem classification system and intervention measures in the Omaha system were evaluated by cross mapping method.@*Results@#A total of 2 609 nursing problems and intervention measures were extracted from the medical records of 68 patients with CHD. Among them, 1 844 (70.68%) records were labeled as "perfect fit", 608 records (23.30%) as "partial fit", and 157 (6.02%) recordsas "not fit at all". The total fit rate was 93.98% (perfect fit and partial fit). The most frequently reported problems were in physiological domain, followed by health-related behaviors domain, psychosocial domain and environmental domain. The nursing interventions extracted accounted for 26.67% (1 968 sentences) of directions and l00.00% (4 kinds) of categories in the intervention scheme of Omaha system.@*Conclusions@#The conceptual congruence between the medical records of patients with CHD and the Omaha System is quite high. It can help to improve nursing problems of patients of CHD in health-related behavioral domain, psychosocial domain and environmental domain, and can be applied to such patients after appropriate adjustment, so as to help clinical nursing staff to provide specialized and all-round guidance for patients with CHD.

A comparative analysis of the Omaha system applied to the nursing description of patients with coronary heart disease / 中国实用护理杂志

Objective To explore the feasibility of applying Omaha system theory to patients with coronary heart disease (CHD) through comparative analysis of nursing description. Methods Using content extraction analysis method, the nursing records, nursing plans and nursing measures of discharged patients with CHD were retrieved from the medical records, and then the conceptual consistency of the extracted records and the problem classification system and intervention measures in the Omaha system were evaluated by cross mapping method. Results A total of 2 609 nursing problems and intervention measures were extracted from the medical records of 68 patients with CHD. Among them, 1 844 (70.68%) records were labeled as "perfect fit", 608 records (23.30% ) as "partial fit", and 157 (6.02% ) recordsas"not fit at all". The total fit rate was 93.98% (perfect fit and partial fit). The most frequently reported problems were in physiological domain, followed by health-related behaviors domain, psychosocial domain and environmental domain. The nursing interventions extracted accounted for 26.67% (1 968 sentences) of directions and l00.00% (4 kinds) of categories in the intervention scheme of Omaha system. Conclusions The conceptual congruence between the medical records of patients with CHD and the Omaha System is quite high. It can help to improve nursing problems of patients of CHD in health-related behavioral domain, psychosocial domain and environmental domain, and can be applied to such patients after appropriate adjustment, so as to help clinical nursing staff to provide specialized and all-round guidance for patients with CHD.

Mapeamento cruzado dos diagnósticos e intervenção de enfermagem de pacientes com insuficiência cardíaca descompensada / Cross-mapping of diagnoses and nursing intervention in patients with decompensated heart failure

Introdução: A insuficiência cardíaca é considerada uma síndrome de grande impacto epidemiológico. Quando apresentada em sua forma descompensada, tende a gerar necessidade imediata de hospitalização, tornando-se o período de maior risco, no qual a chance de morte é significativamente mais elevada. Portanto, é essencial conhecer os diagnósticos e intervenções de enfermagem específicos para esses pacientes no momento da admissão. Objetivo: Mapear os diagnósticos de enfermagem da NANDA Internacional e as intervenções de enfermagem da Classificação de Intervenções de Enfermagem a partir do cruzamento dos termos encontrados nos registros de enfermagem de pacientes admitidos com insuficiência cardíaca descompensada. Método: Trata-se de um mapeamento cruzado dos termos encontrados nos registros de enfermeiros em 107 prontuários eletrônicos de pacientes admitidos por insuficiência cardíaca descompensada no período de outubro de 2017 a fevereiro de 2019 de um hospital de referência em cardiologia do município do Rio de Janeiro/RJ. Os diagnósticos e intervenções mapeados foram avaliados quanto a relevância por quatro peritos. A análise de concordância entre os mesmos foi verificada pelo índice de validação de conteúdo e o Kappa de Fleiss. Resultados: As características clínicas apresentadas demonstraram-se clássicas de pacientes com insuficiência cardíaca descompensada. Os diagnósticos de enfermagem da NANDA Internacional mais frequentes foram: risco de infecção (74,8%), débito cardíaco diminuído (55,1%), volume de líquidos excessivo (49,5%). As intervenções de enfermagem mapeadas foram: monitoração de sinais vitais (79,4%), monitoração hídrica (72,9%) e posicionamento (52,3%). Conclusão: Conclui-se que existe a necessidade de uma capacitação para que enfermeiros especializados realizem julgamentos mais específicos acerca das respostas de pacientes com insuficiência cardíaca descompensada. O estudo trará benefícios para assistência, suporte para pesquisas voltadas nesta área e para futura implementação de Sistemas de Classificações em prontuários eletrônicos, auxiliando a comunicação entre profissionais que atuam diretamente com pacientes portadores da síndrome.

Introduction: Heart failure is considered an epidemiologic syndrome of substantial impact. Hence, when it is presented in its decompensated form, it tends to generate an emergency hospitalization need, becoming the highest risk period, which death chance is significantly greater. Therefore, knowing the diagnosis and specific nursing interventions to these patients are essential in the admission process. Objective: Mapping the NANDA International nursing diagnosis and the Nursing Interventions Classification on nursing interventions by crossing the findings in nursing observations records from patients admitted with decompensated heart failure. Methodology: This work is based in cross mapping of the findings in the nursing observations of 107 digital patient records of patients admitted with decompensated heart failure from October 2017 to February 2019 in a reference specialized heart disease hospital in Rio de Janeiro/RJ. The diagnosis and interventions mapped were analyzed for relevance by four experts. The correlation analysis between them was verified by the content validation index and the Kappa de Fleiss. Results: The presented clinical characteristics were demonstrated to be those typical in decompensated heart failure patients. The most frequent NANDA International nursing diagnosis were Risk for Infection (74.8%), Cardiac Output Alteration (55.1%), Fluid Volume Excessive (49.5%). The mapped nursing interventions were Vital Signs Monitoring (79.4%), Fluid monitoring (72.9%) and Positioning (52.3%). Conclusion: It may be concluded that it is necessary for specialized nurses to be capacitated in order to perform more specific judgments regarding the response to patients with decompensated heart failure. The study will bring benefits to the assistance, support to researches in this field and to the future implementation of Classification Systems in digital patient records, helping the communication between professionals that perform directly with patients with that syndrome.

Tecnologias de informação e registro do processo de enfermagem: estudo de caso em UTI neonatal / Information technologies and nursing process records: case study at a neonatal ICU

Objetivou-se analisar o registro do Processo de Enfermagem apoiado por tecnologias de informação e comunicação em meio impresso e eletrônico, no cenário de terapia intensiva neonatal. Estudo de caso único, integrado, desenvolvido de janeiro a abril de 2014. Participaram sete enfermeiros que atuavam na UTI neonatal antes e após a implantação de novas tecnologias de informação e comunicação (NTICs), que combinavam suporte eletrônico e físico (papel). Coletaram-se dados por meio de extração de registros dos prontuários e questionário aplicado aos enfermeiros. Para análise utilizou-se frequência simples e percentual dos níveis de aplicação do processo de enfermagem, e o conjunto de fatores intervenientes relativos à estrutura e processo de organização do trabalho. Encontraram-se resultados positivos e negativos e fatores intervenientes. Conclui-se que as NTICs em meio físico foram responsáveis pelo registro de maior número de registros na coleta de dados e que o registro das demais etapas não apresentou melhora substancial.

The objective of this study was to analyze the recording of the nursing process, supported by information and communication technologies in both printed and electronic media in the neonatal intensive care scenario. This case study was exclusive, integrated, and conducted between January and April 2014. The study counted on the participation of seven nurses who worked at a neonatal ICU before and after the deployment of new information and communication technologies, which combined electronic and physical (paper) support. Data were collected from medical records and a questionnaire answered by the nurses. Simple and percentage frequency in the levels of the nursing process application were used for analysis, as well as the set of intervening factors related to the work organization structure and process. Positive and negative results were seen, as well as intervening factors. The study concluded that the new information and communication technologies delivered in physical materials accounted for the registration of the higher number of records in the data collection and that the registration of the other stages did not show any substantial improvement

Effects on Knowledge and Performance in Clinical Nursing of Education on Nursing Recording Focusing on Legal Aspects / 간호행정학회지

PURPOSE: The purpose of this study was to examine the effects on knowledge and performance in clinical nurses who participated in education on nursing recording focusing on the legal aspects. METHOD: The participants were working in medical departments in one hospital. There were 32 nurses in the experimental group and 25 in the control group. Pre-test was conducted on the two groups before education, and, in order to examine the effects of education, a post-test was conducted after three weeks. For the experimental group, the education on nursing recording focusing on legal aspects was provided as a lecture-led one-to-one training. RESULTS: Significant differences were found between the experimental and control groups in knowledge (F=15.728, p<.001), and performance (F=42.454, p<.001). CONCLUSIONS: The results of this study indicate that education on nurse recording enhances the knowledge and performance of the nurses. Thus education on nurse recording focusing on legal aspects should be required in the area of nursing science.

Crossmapping of Nursing Problem and Action Statements in Telephone Nursing Consultation Documentations with International Classification for Nursing Practice / 대한의료정보학회지

OBJECTIVES: This study is to cross-map telephone nursing consultation documentations with International Classification for Nursing Practice (ICNP; ver. 1.0 concepts). METHODS: The narrative telephone nursing consultation documentations of 170 ophthalmology nursing unit patients were analyzed. The nursing statements were examined and cross-mapped with the Korean version of the ICNP ver. 1.0. If all the concepts of a statement were mapped to ICNP concepts, it was classified as 'completely mapped'. If any concept of a statement wasnot mapped, it was classified as 'partially mapped'. If none of the concepts were mapped, it was classified as 'not mapped'. RESULTS: A total of 738 statements wereused for documenting telephone nursing consultations. These statements were divided into 3 groups according to their content: 1) 294 nursing phenomena-related statements (72 unique statements), 2) 440 nursing actions-related statements (76 unique statements), and 3) 4 other statements (2 unique statements). In total, 189 unique nursing concepts extracted from 150 unique statements and 108 concepts (62.44%) were mapped onto ICNP concepts. CONCLUSIONS: This study demonstrated the feasibility of computerizing narrative nursing documentations for electronic telephone triagein the ophthalmology nursing unit.

Comparison of Nursing Records of Open Heart Surgery Patients before and after Implementation of Electronic Nursing Record / 대한의료정보학회지

OBJECTIVES: The objective of this study is to compare nursing records before and after the implementation of an electronic nursing records system. METHODS: Twenty patients' paper-based nursing records and 20 patients' electronic nursing records were analyzed according to the nursing process and compared in terms of quantity and quality. RESULTS: In terms of quantity, the average number of statements documented per patient per day has increased by 2.5 times, from 10.3 to 25.6 statements. The average number of redundancies of a unique statement also has increased by 67%, from 5.0 to 8.8. As for the content of nursing records, paper-based nursing records have more patient problem statements describing signs and symptoms, nursing observations, and patient status. Electronic nursing records have more nursing activity statements. In terms of quality, there were more nursing records following patterns of nursing process in electronic nursing records than paper-based nursing records. The electronic nursing records have a more detailed documentation compared to the paper-based nursing records. CONCLUSION: After the implementation of electronic nursing record system, quantity of nursing records and the pattern of nursing records following the nursing process have been increased and granularity of nursing records has been improved.

The design and management of nursing case records for patients with acute cerebrovascular disease / 中国实用护理杂志

Objective To discuss the design and content management of the nursing case records for patients with acute cerebrovascular disease.Methods We modified the former nursing case records(NCR)by adopting the "filling in the blank" recording style and reducing time cost for repeated writing.The new NCR demonstrated the time characteristic of vital signs changes and neurological signs changes such as consciousness,pupil and paralyzed muscle strength.It could also superintend the record of admission,hospitalization and discharging of patients.Results It met a standardized nursing record management after the modification and showed the specialized nursing services with simplified and integral characteristics.The new NCI fitted legal requirement,pretected the rights of nurses and favored for the quality control and management of nursing cases.Conclusion The newly modified NCI contributes to the nursing quality for hospitalized patients with acute cerebrovascular disease.

Analysis of Nursing Activity in General Hospital Using Hospital Information System / 대한의료정보학회지

OBJECTIVES: This study intended to identify the staff nurse's activity in general hospital, where its Hospital Information System is well established and Electronic Nursing Record System was being used for 2 years. METHODS: Procedure was done with the following steps; In the first step, nursing activity time was analysed by checklist, which 28 nurses filled out by themselves. The group interview was followed. RESULTS: During the day shift, the direct nursing activities took 37.04%, indirect nursing 40.74%, ward management 18.52% and personal time 3.70% respectively. In evening shift, nurses used 29.41% on direct nursing, 45.10% on indirect nursing, 19.61% on ward management and 5.88% on personal time. In night shift, direct nursing took 17.91%, indirect nursing 46.27%, ward management 17.91% and personal time 11.98%. The group interview reported the differences in nursing activities which recognized by the included staff nurses after the introduction of ENR; speed and convenience in working, the correctness and speed of recording, reduction of indirect nursing time including recording time and increase of direct nursing time and patient education. CONCLUSIONS: The introduction of HIS including ENR system was verified to be effective on improvement of nursing quality, by bringing reduction of indirect nursing time and increase of direct nursing time.

Analysis of the Nursing Practice in a Medical ICU Based on an Electronic Nursing Record / 간호학회지

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.

Formative Evaluation of Standard Terminology-based Electronic Nursing Record System in Clinical Setting / 대한의료정보학회지

The Objectives of this study are to evaluate the user satisfaction and actual data input time through an enterprise ICNP-based electronic nursing record system using the controlled vocabulary in a secondary care hospital (BSNUH). Study design is a formative evaluation using the QUIS (Questionnaire user interaction satisfaction) self-reported in a secondary care hospital operating EMR(electronic medical record) system in Korea. Participants were two hundred fifty nurses in BSNUH. All of them were registered nurses participated in day-to-day nursing care during study periods. Participants were asked to fill in the SNCEQ(The Staggers Nursing Computer Experience Questionnaire) and QUIS(Questionnaire for User Interaction Satisfaction). Also requested were the data input time(sec) required for entry of approximately 20 times of nursing documentation tasks and the number of standardized precoordinated phrases used for documenting routine nursing records. The mean score of user satisfaction was 4.56 (SD 1.25) and the mean time of data input and the average number of precoordinated phrases used in nurses notes was 2.25min and 3.7 respectively.

Contents Analysis of Paper-Based Nursing Documents for Electronic Nursing Record Using ICNP / 대한의료정보학회지

The purpose of this study was to seek the approach structuring the descriptive nursing documents and using the terminology as controlled vocabula ry in elec tronic nursing r ecord through the analysis of contents re corded in paper-based nursing documentation forms with the International Classification for Nursing Practice(ICNP). Sixty three patients'nursing re cords, corresponding to documents of 395 days of a teaching Hospital in Seoul were used. From the chart review of the 5 nursing record forms; Nurses'note, Deliver y Floor Nur sing Record I, II, Nur sing History Record(Mate rnity), Nur sing Discha rge Plan(Maternity), na rrative da ta and formatted data wer e collecte d and analyzed separately. Na rrative data were broke down semantically into single sentences and classified according to the semantics. Formatted data were summarized by concepts from the nursing forms'items. Fourteen thousand seven hundred twenty-seven statements and sixty-three items were analyzed. In the process of decomposing the narrative data into single statements, a constant pattern of contents like the nursing process and some contextual information, such as the other health professions'behaviors or plans which were not classified in nursing phenomena or actions, were found. The 14,727 statements were represented into 237 unique statements and decomposed into 259 unique concepts. Among those 39.8%(103) were identified as local vocabulary, which represents the concrete concepts in detail in the maternity nursing field. In the analysis of 48 formatted items, 23(47.9%) concepts were local vocabulary. These study findings implied the effective method of structuring the narrative nursing documents and supported the importance of identifying the local vocabulary in terminology of ICNP based approach to improve and complement the expressiveness of clinical practice in detail enough.

Nursing Knowledge/Power and Practice in Pediatric Intensive Care Unit / 아동간호학회지

The purpose of this study was to reveal what influences the divergent methodological researches have brought the nursing practice in during the past 3 decades. The nursing record sheets ie, the nursing discourses were analyzed to know the knowledges that were recorded, accepted and communicated in nursing practice at pediatric intensive care units, and unclosed the philosophical and methodological position of that knowledges. The texts were 13 sheets, 3 kinds of nursing record(7 24hours flow charts, 4 nursing information record sheets and 2 transfer record sheets) used at 4 hospitals. The unit of analysis was 'word'. First, all words of the sheets were listed up, clustered into categories based on their contents. And then, the larger conceptual themes were drawn to elucidate the effect of the knowledge/power and the philosophical and methodological position of that knowledges. To enhanced the validity of the analysis, the data were analyzed by two researchers. The 'words' were classified into 3 categories; 'general information', 'assessment' and 'intervention'. The conceptual themes of the texts were 'the gaze for quantification and objectification' and 'technical/assimilated caring'. This themes reflected the logic positivistic and biomedical view that had dominated at clinical practice. Nursing has endeavored to resist the logic- positivistic knowledge/power and to established the nursing knowledge/power based on multiple philosophies and methodologies, especially phenomenological-interpretative. But the results of this study revealed that such efforts in nursing theory and research couldn't influenced the knowledge of practice. Logic positivism was yet so strong and the biomedical model yet dominated in the clinical practice. It identified that the borrowed theory and the knowledge from the received view gave nursing the power. But they were modalities that reinforced the dominant, medical power. Nursing has investigate the other positions (feminism, Habermas' critical social theory and Foucault's discourse theory). This positions suggest different assumptions but share the common concepts; equality, emancipation and freedom. The important point is how make these concepts the practical for nursing knowledge/ power in practice. We must recognize that the praxis at clinical setting take place at the field unlike theoretical praxis. The change of clinical practice is the social, economic and political change.

Standardization of Nursing Documents for Special Nursing Units / 대한의료정보학회지

The purpose of this paper is to introduce standardization activities of nursing documentation for special nursing units following standardization efforts for general nursing units last year. Modified Delphi approach with expert panel was used to identify essential nursing documents and data set for each units. Expert panel was consisted of head nurses or charge nurses of each special nursing unit from 8 tertiary hospitals with more than 500 beds in Seoul. the secretary-general of Clinical Nurses Association and a faculty of College of Nursing. The exiting nursing forms of seven special nursing units, which include Emergency room, Intensive care unit, Operating room, Respiratory intensive care unit. Delivery floor. Nursery and Dialysis room, were analyzed and prototypes of the standard nursing forms and guidelines were developed. The clinical field test was done with the help of Clinical Nurses Association. At the field test 3.744 clinical staff nurses from 20 tertiary hospitals with more than 500 beds in Korea were involved and provided feedback. Finally public hearing was held and more than 600 nurses from 116 hospitals attended and provided feedback. Through these process consensus of nursing community was attained for standard documents and data items. The result is available at http://nursing.snu.ac.kr/standard/ through internet.

A Study on the Effects of EMR on Nursing Documentation / 대한의료정보학회지

To improve the quality of nursing care, we developed and evaluated a Electronic Medical Record (EMR) program designed to maximize productivity and efficiency in our nursing documentation system. Five computerized documentation forms, the clinical observation record, medication, nursing treatments, nursing records, and admission assessment were developed by a nursing informatics team over 5 months and implemented on a cardiovascular unit. In the EMR program, nurses access and record required documentation at the patients besides with a laptop computer instead of using conventional chart. Four categories of data were compared before and after operating EMR program; the time spent in direct patient care, the time spent in nursing documentation, nurses' s job satisfaction, and patients' satisfaction. The result showed a statistically significant increase in the time spent in direct patient care after implementation of EMR system, as well as a decrease in the time spent in nursing documentation. Nurses job satisfaction was increased and patients' satisfaction was decreased, but both were not significant statistically.

A Basic Study on Improvement and Computerization of Nursing Record / 간호학회지

This study was designed to develop a basic plan for computerization of nursing records. The subjects were 7 nursing record forms, 58 charts, 23 nurses, 2 nurses managers, a nurse and computer specialist, 16 master course students and 3 professors. Data collection was conducted through questionnaire, observation and interview. The collected data were analyzed for problems, plan of improvement and needs for computerization. Based upon these results, it is recommended that nursing record computerization was needed a basic plan to integrate needs of nursing record computerization. The basic plan as follows: 1. To illustrate a data flow path of nursing record and data dictionary that show nurse's work and record process. 2. To establish a system in order to use multi-tasking and graphic user interface. 3. To establish hardware and software in order to embody integrated management of computer based system through structured walk through. 4. To choose effective database management system and to achieve Log as record unit.

A Basic Study on Improvement and Computerization of Nursing Record / 간호학회지

This study was designed to develop a basic plan for computerization of nursing records. The subjects were 7 nursing record forms, 58 charts, 23 nurses, 2 nurses managers, a nurse and computer specialist, 16 master course students and 3 professors. Data collection was conducted through questionnaire, observation and interview. The collected data were analyzed for problems, plan of improvement and needs for computerization. Based upon these results, it is recommended that nursing record computerization was needed a basic plan to integrate needs of nursing record computerization. The basic plan as follows: 1. To illustrate a data flow path of nursing record and data dictionary that show nurse's work and record process. 2. To establish a system in order to use multi-tasking and graphic user interface. 3. To establish hardware and software in order to embody integrated management of computer based system through structured walk through. 4. To choose effective database management system and to achieve Log as record unit.

The Development of the Critical Pathway and Nursing Record for Patients received FP Chemotherapy / 성인간호학회지

The current patient management system has several limitations. To develop the critical pathway (CP) as a cost-effective method via continuous patient management, we investigated the medical records of 77 patients who underwent FP chemotherapy in Seoul National University Hospital from Feb, 1 to 28, 1999. And the pilot study was done to 12 patients admitted to undergo the FP chemotherapy. 1. The vertical contents in the CP consisted of 7 items; assessment, activity, diet, IV therapy, medication, education and evaluation. The duration of the horizontal axis was 6 days from admission to discharge. 2. The medical performance according to the vertical axis in the preliminary CP, consisted of 72 , and modified to 74 items in the final form of CP. 3. The nursing record consisted of a vertical axis of 4 items; assessment, IV therapy, medication and education. The duration of the horizontal axis was 6 days from admission to discharge of hospital days.

Analysis and Standardization of Nursing Record Forms for Nursing Informatics Standard / 대한의료정보학회지

This paper reflects on the standardization activities of nursing documentation. Even though nurses are the most important manpower in terms of collecting patients' data, nursing documentation have been overlooked in the process of developing electronic patients records. It is impossible to complete a computerized patient record system without including nursing documentation. Standardization of nursing documentation is the first step toward a computerized documentation system. In this study nursing documentation forms were gathered from 11 tertiary hospital with more than 500 beds in Seoul. Out of various nursing documentation, 9 essential forms were chosen to standardize. They are admission assessment, form, nursing treatment record, nursing care plan, discharge planning record, patient transfer record, clinical observation record, nursing treatment record, nursing progress notes, critical care flow sheet, and preoperative checklist Forms and data elements were reviewed and analyzed. It was learned that there is no one perfect from that could be used in any agency. Data elements were analyzed and standardized. Data elements to be included in each form were selected. Standardized forms were developed with the selected data element. Guideline outlining how to use each nursing form were developed. Now it is in the process of validating the forms and the guidelines at 240 nursing units at 8 tertiary hospitals. The results of the validation study will be incorporated in the final version of nursing forms and they will be introduced to general nursing population at an open forum to be held by Korean Nurses Association at the end of this year. This standardization activities will have a great impact on nursing practice, education, administration and research.