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Analysis of Medical Records and Development of Chest Pain Care Record in the Emergency Department / 성인간호학회지
Journal of Korean Academy of Adult Nursing ; : 533-542, 2006.
Article in Korean | WPRIM | ID: wpr-210786
ABSTRACT

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.
Subject(s)

Full text: Available Index: WPRIM (Western Pacific) Main subject: Thorax / Chest Pain / Nursing Records / Medical Records / Retrospective Studies / Statistics as Topic / Nursing / Emergencies / Emergency Service, Hospital Type of study: Observational study / Risk factors Limits: Humans Language: Korean Journal: Journal of Korean Academy of Adult Nursing Year: 2006 Type: Article

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Full text: Available Index: WPRIM (Western Pacific) Main subject: Thorax / Chest Pain / Nursing Records / Medical Records / Retrospective Studies / Statistics as Topic / Nursing / Emergencies / Emergency Service, Hospital Type of study: Observational study / Risk factors Limits: Humans Language: Korean Journal: Journal of Korean Academy of Adult Nursing Year: 2006 Type: Article