• 대한간호학회지
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• 제49권5호
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• pp.575-585
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• 2019

Purpose: The purpose of this study was to develop predictive models for pressure ulcer incidence using electronic health record (EHR) data and to compare their predictive validity performance indicators with that of the Braden Scale used in the study hospital. Methods: A retrospective case-control study was conducted in a tertiary teaching hospital in Korea. Data of 202 pressure ulcer patients and 14,705 non-pressure ulcer patients admitted between January 2015 and May 2016 were extracted from the EHRs. Three predictive models for pressure ulcer incidence were developed using logistic regression, Cox proportional hazards regression, and decision tree modeling. The predictive validity performance indicators of the three models were compared with those of the Braden Scale. Results: The logistic regression model was most efficient with a high area under the receiver operating characteristics curve (AUC) estimate of 0.97, followed by the decision tree model (AUC 0.95), Cox proportional hazards regression model (AUC 0.95), and the Braden Scale (AUC 0.82). Decreased mobility was the most significant factor in the logistic regression and Cox proportional hazards models, and the endotracheal tube was the most important factor in the decision tree model. Conclusion: Predictive validity performance indicators of the Braden Scale were lower than those of the logistic regression, Cox proportional hazards regression, and decision tree models. The models developed in this study can be used to develop a clinical decision support system that automatically assesses risk for pressure ulcers to aid nurses.

• 성인간호학회지
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• 제21권3호
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• pp.349-354
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• 2009

Purpose: The purpose of this study was to determine core nursing intervention in nursing records and to compare perceived nursing intervention priority and nursing intervention frequency of general surgery department. Methods: Subjects were 70 nurses who work in the general surgery department. Data was collected using a nursing intervention classification and analyzed by frequency and mean. Results: The most frequent nursing interventions of nursing records were orderly risk management, coping assistance, tissue perfusion management, skin/wound management and nutrition support. Important nursing interventions were tissue perfusion management, respiratory management, electrolyte acid-base management, elimination, peri-operative care. The most frequent nursing interventions were drug management, peri-operative care, risk management, tissue perfusion management, patient education. Conclusion: This study found that nursing records were different from intervention priority and nursing frequency. So further study is needed for finding focused intervention of specific subjects and differences with priority of nursing and frequency of nursing.

• 한국산학기술학회:학술대회논문집
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• 한국산학기술학회 2010년도 춘계학술발표논문집 2부
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• pp.837-840
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• 2010

본 연구는 급변하는 의료환경에 대비하여 간호의 질 향상 및 증진을 통한 환자 만족도 증진을 위해 간호전달체계를 기능적 간호방법에서 팀간호제 방법으로 전환을 하면서 이에 따른 간호활동 및 직무 만족도를 조사하였다. 간접간호 수행률 조사를 살펴보면 기록간호, 확인업무, 물품관리, 간접소통, 전달 업무 등 모두에서 유의한 차이를 보이지 않았다. 영양간호, 전적인 식사보조 등은 간호직무만족도가 영향을 미치는 것으로 나타났다. 간호사 직무만족도는 어려움이 있을 때 동료나 상사에게 의논하는 것으로 나타났다. 안전간호, 화재예방 등이 영향을 미치는 것으로 나타났다. 간호사 업무성과 병동의 시설과 기구를 적절히 관리한다. 간호사 업무성과, 환자에게 적절한 휴식 및 안정을 위한 간호를 제공하는 것으로 나타났다. 본 연구 결과 간호사들이 역할을 명확히 규명하고 세분화하여 이를 수행하는 직무내용을 명확하게 파악하고 작업표준 지침서를 작성하여 활용한다면 간호사들의 자가 관리 증진은 물론 환자와 보호자에게도 만족감을 높여 줄 수 있는 계기가 될 것이며, 이를 통한 다양한 팀제 운영이 될 것이라 생각된다. 또한, 향후 다양한 업무 개선 활동이 가능할 것이라 생각된다.

• 한국기록관리학회지
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• 제17권3호
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• pp.115-138
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• 2017

전자기록물의 유형은 다양해지고 있으며, 기능성이나 사용자와의 상호작용을 포함하며 여러 종류의 전자기록으로 구성된 기록물인 복합전자기록물들이 증가하고 있다. 복합전자기록물의 지속적인 접근을 보장하기 위해서는 아카이빙을 지원할 수 있는 메타데이터 구축이 필수적이다. 본 연구는 이러닝 콘텐츠인 복합전자기록물의 아카이빙을 위한 메타데이터 요소를 설계하여 제안하였다. 국내외의 장기보존을 위해 설계된 포맷 레지스트리의 구성요소를 비교 분석하여 디지털 아카이빙에 필수적인 공통 메타데이터 요소를 도출하고, 간호 분야 이러닝 콘텐츠의 보존 속성을 조사, 분석하여 이를 반영할 수 있도록 메타데이터 요소를 확장, 추가하였다. 분석결과를 통해 복합전자기록물 아카이빙을 지원하는 메타데이터 상위요소 25개와 138개의 하위요소가 제안되었다.

• 간호행정학회지
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• 제2권1호
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• pp.73-96
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• 1996

In the complexity and diversity of modern society, there is an urgent need for an information system which can systematically collect, manage and analyze data. Especially in the discipline of nursing, a nursing informarion system is necessary to maximize nursing resources and improve nursing care in the present system which is faced with increases in client needs and multiple changes in hospital environments. This research was done to provide a basis for the development of an integrative nursing information system for the future, by designing dababases items which were extracted from an analysis of the ward nursing information system on general wards excluding the OPD, ICU, OR and CSR with functions using a different system from the wards, and the design of output screen used the database items. The ward nursing information system was analysed through analysis of nursing practice related to recordings, such as the worksheet, kardex, and other nursing practice recordings, on 25 wards. The development of the database was the part of the construction of hospital information system and used the database development life cycle which is related to the system development life cycle. The database development steps included selection of database management system and design of a physical database following the principles of the order communication system which is been developing at Y University Hospital. Conceptual database and Logical database were designed using the base of 25 data items and fields derived from analysing the worksheet, the data items and fields derived from the kardex and other nursing practice recording, from these 19 data base tables were framed through transforming the relational database. Through this process, four types of output material for nursing practice recording which nurses can carry and use during their nursing practice were produced.

• Journal of Korean Biological Nursing Science
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• 제15권4호
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• pp.164-172
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• 2013

Purpose: The aim was to measure the real-time trans-mission effect of blood-pressure and blood-glucose value based on u-healthcare for saving the time and effort of nursing recording time. Methods: This study used a u-healthcare system based on the international standards for the exchange of health information. In order to verify the effectiveness of the u-healthcare, a clinical trial for the system regarding blood-pressure and blood-glucose targeting of patients with endocrine disorders at KNUH from February 7 to 9, 2012 was performed. Results: According to the analyzed results, of the 86 times the 11 patients were tested, measuring blood-pressure and blood-glucose using the u-healthcare system, we found the time differences between the real-time transfer recording method and existing hospital records that were used in the hospital. Based on the average time interval, there was a difference of 1,090.45 seconds (18.17 minutes). Conclusion: Therefore, it's cumbersome that nurses in the hospital have to record the numerical values of the measured blood-pressure and blood-glucose manually and input the recorded values directly into the electronic nursing record system. However, it was found in terms of the newly designed system, that it could save time and effort for nurses, since measured information is sent to the hospital information system on a real-time basis.

• Perspectives in Nursing Science
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• 제9권2호
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• pp.146-153
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• 2012

Purpose: The aims of this study were to analyze the frequency of standard nursing statements used in the Electronic Nursing Record (ENR) and to evaluate the degree of satisfaction by users of the ENR system. Methods: We retrospectively reviewed the ENR of 1914 patients who were admitted to our center between 1 May 2011 and 31 May 2011. Additionally, we collected questionnaires from 100 doctors and 300 nurses to evaluate the satisfaction of the users. Results: The frequency of use for the following standard nursing statements was investigated: standard nursing assessment statements (43.6%), standard nursing diagnosis statements (61.8%), standard nursing plan statements (46.7%), standard nursing intervention statements (56.9%), and standard nursing evaluation statements (41.7%). The mean satisfaction score was 3.03 out of 5 in the nurse's group, and 3.11 in the doctor's group. The nurses said the advantages of the ENR system were as follows: easy to access, informative, and standardized terms. However 75.7% of the nurse answered that they cannot express actual nursing situations exactly with the currently limited standard nursing statements. Conclusion: Development of various standard nursing statements is needed to meet the demands of the users. As a result, the use of the ENR system would become easier and more efficient for its users.

• 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.

• 한국산학기술학회논문지
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• 제16권11호
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• pp.7447-7455
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• 2015

본 연구는 간호학생의 재난준비도와 재난간호 핵심수행능력 및 교육요구도를 파악하여 재난간호 교육과정 개발을 위한 기초자료를 제공하고자 시행된 조사연구로 D 지역 간호대학 및 간호학과 4학년 252명을 대상으로 시행되었다. 연구결과 대상자의 재난간호 수행능력은 평균 2.76이었으며, 재난간호 수행능력중 "재난상황시 문서기록절차"가 2.34, "소속기관의 재난관련지침"이 2.37로 가장 낮았다. 또한, 대상자의 재난준비도는 평균 2.14이었으며, 가장 낮은 항목은 "집에서의 재난대피연습" 항목이었다. 대상자의 재난간호 핵심수행능력에 영향을 미치는 요인으로는 재난준비도(${\beta}$=.48), 재난교육요구도(${\beta}$=.21), 성적(${\beta}$=.26), 재난교육 여부(${\beta}$=-.11)로 나타났다. 본 연구결과 간호학생의 재난준비와 재난간호 핵심수행능력은 부족한 실정으로 나타났으며 재난간호에 대한 교육이 절실히 필요하며 간호대학생을 위한 재난간호 교육과정 개발을 위한 교육내용에 대한 연구가 필요하다.

• 임상간호연구
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• 제21권3호
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• pp.377-388
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• 2015

Purpose: To identify user requirements for electronic nursing record (ENR) systems so as to ensure system usability. Methods: A mixed methods approach were applied in three steps : (i) task and workflow analysis with literature review of nursing documentation, (ii) literature reviews of system usability, and (iii) Use Case idenfication and consensus-based validation. We analyzed the nursing activity logs collected from a time-motion investigation of six hospitals. The Use Cases were validated by eight clinical experts from different hospitals and two experts from academia in a sequential Delphi survey. Consensus was achieved for the significance score and agreement among the panel. Results: Eight task groups and patterns of task flow were observed, which were translated into nine Use Cases. The specification of Use Cases was derived from principles, guidelines, and recommendations on nursing documentation and electronic health record systems, which was organized into three requirements of each Use Case: functionality, information, and design characteristics. Each Use Case achieved an agreement of 50~70%, and significance scores of 4 or 5 on a 5-point Likert scale. Conclusion: The nine Use Case identified were considered to be important and adequate in terms of both clinical and informatics contexts.