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.
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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