• Title/Summary/Keyword: Documentation Guideline

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Updates of Nursing Practice Guideline for Enteral Nutrition (경장영양 간호실무지침 개정)

  • Cho, Yong Ae;Gu, Mee Ok;Eun, Young;Yu, Mi;Kim, Jung Yeon;Lee, Hyun Hee;Min, Ja Kyung;Song, Jung Mi
    • Journal of Korean Clinical Nursing Research
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    • v.26 no.1
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    • pp.10-25
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    • 2020
  • Purpose: The purpose of this study was to update the previously developed nursing practice guideline for enteral nutrition (EN). Methods: The guideline update was done in 22 steps using standardized methodology for nursing practice guidelines. Results: The updated EN guideline consisted of 16 domains and 228 recommendations. The domains and number of recommendations in each domain were for IDSA (Infectious Diseases Society of America): 8 on general instruction, 9 on general instruction for special nutrition, 9 on general instruction for EN, 3 on assessment of EN, 10 on access to EN, 18 on EN device insertion, 16 on selection and preparation of nutritional supplements, 46 on administration and stopping EN, 22 on maintenance and management of EN, 9 on monitoring EN, 16 on prevention and management of complications of EN, 18 on medication administration, 20 on EN in various situations, 20 on prevention of errors, 1 on nursing education, and 3 on nursing documentation. For the levels of evidence, there were 9.7% for level I, 13.1% for level II, 62.5% for level III and 1.1% for GRADE (Grading of Recommendations Assessment, Development and Evaluation): 3.3% for low, 0.8% for moderate, 9.3% for very low. A total of 133 recommendations were newly developed and 10 previous recommendations were modified. Conclusion: This updated EN nursing practice guideline can be used to enhance evidence-based practice in fundamentals of nursing practice and it should be disseminated to nurses nationwide in order to improve the efficiency of EN practice.

Performance of Evidence-based Pain Assessment and Management Guidelines among Medical-Surgical Nurses (내·외과 간호사의 근거기반 통증사정 및 관리 가이드라인 수행도)

  • Kim, Heui Lyang;Song, Chi Eun;So, Hyang Sook
    • Korean Journal of Adult Nursing
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    • v.28 no.5
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    • pp.546-558
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    • 2016
  • Purpose: This study aimed at the effectiveness to investigate the performance of evidence-based pain assessment and management guidelines. Methods: Participants were 140 nurses at the med-surgical units. Data were collected in early July, 2014 using Registered Nurses Association of Ontario (RNAO) guideline (2007) revised and validated by Hong and Lee (2012) and analyzed by descriptive statistics, t-test, ANOVA using SPSS/WIN18.0. Results: The score of performance of pain assessment guideline was higher than the score of pain management. Categories with high score were pain screening, parameter of pain assessment, documentation, assessment of opioids side-effects, and record of pain caused intervention. Categories with low score were comprehensive pain assessment, multidisciplinary communication, establishing a plan for pain management, consultation and education for patients and their families, and education for nurse. Non-pharmacological management was the lowest one. Conclusion: Assessing and managing pain is a complex phenomenon. It might be useful if institutions host training programs to ensure that nurse are better able to understand and implement pain assessment and management. Since non-pharmacological management is less likely to be used by nurses it may be helpful to include these methods in a training program.

Identifying Minimum Data Sets of Oral Mucous Integrity Assessment for Documentation Systematization (구강점막의 통합성 사정기록 체계화를 위한 최소자료세트(Minimum Data Set) 규명)

  • Kim, Myoung Soo;Jung, Hyun Kyeong;Kang, Myung Ja;Park, Nam Jung;Kim, Hyun Hee;Ryu, Jeong Mi
    • Journal of Korean Critical Care Nursing
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    • v.12 no.1
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    • pp.46-56
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    • 2019
  • Purpose : The purpose of this study was to identify minimum data sets for oral mucous integrity-related documentation and to analyze nursing records for oral care. Methods: To identify minimum data sets for oral status, the authors reviewed 26 assessment tools and a practical guideline for oral care. The content validity of the minimum data sets was assessed by three nurse specialists. To map the minimum data sets to nursing records, the authors examined 107 nursing records derived from 44 patients who received chemotherapy or hematopoietic stem cell transplantation in one tertiary hospital. Results: The minimum data sets were 10 elements such as location, mucositis grade, pain, hygiene, dysphagia, exudate, inflammation, difficulty speaking, and moisture. Inflammation contained two value sets: type and color. Mucositis grade, pain, dysphagia and inflammation were recorded well, accounting for a complete mapping rate of 100%. Hygiene (100%) was incompletely mapped, and there were no records for exudate (83.2%), difficulty speaking (99.1%), or moisture (88.8%). Conclusion: This study found that nursing records on oral mucous integrity were not sufficient and could be improved by adopting minimum data sets as identified in this study.

Updates of Evidence-Based Nursing Practice Guideline for Prevention of Venous Thromboembolism (근거기반 정맥혈전색전증 예방 간호실무지침 개정)

  • Cho, Yong Ae;Eun, Young;Lee, Seon Heui;Jeon, Mi Yang;Jung, Jin Hee;Han, Min Young;Kim, Nari;Huh, Jin Hyung
    • Journal of Korean Clinical Nursing Research
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    • v.29 no.1
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    • pp.24-41
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    • 2023
  • Purpose: This study aimed to update the previously published nursing practice guideline for prevention of venous thromboembolism (VTE). Methods: The guideline was updated according to the manuals developed by National Institute for Health and Care Excellence (NICE) and Scottish Intercollegiate Guidelines Network (SIGN), and a Handbook for Clinical Practice Guideline Developer Version 10. Results: The updated nursing practice guideline for prevention of VTE was consisted of 16 domains, 46 subdomains, and 216 recommendations. The recommendations in each domain were: 4 general issues, 8 assessment of risk and bleeding factors, 5 interventions for prevention of VTE, 18 mechanical interventions, 36 pharmacological interventions, 36 VTE prevention starategies for medical patients, 25 for cancer patients, 13 for pregnancy, 8 for surgical patients, 7 for thoractic and cardiac surgery, 16 for orthopedic surgery, 10 for cranial and spinal surgery, 5 for vascular surgery, 13 for other surgery, 3 educations and information, and 2 documentation and report. For these recommendations, the level of evidence was 32.1% for level I, 51.8% for level II, and 16.1% for level III according to the infectious diseases society of America (IDSA) rating system. A total of 112 new recommendations were developed and 49 previous recommendations were deleted. Conclusion: The updated nursing practice guideline for prevention of VTE is expected to serve as an evidence-based practice guideline for prevention of VTE in South Korea. It is recommended that this guideline will disseminate to clinical nursing settings nationwide to improve the effectiveness of prevention of VTE practice.

Adaptation of Intravenous Infusion Nursing Practice Guideline (정맥주입요법 간호실무지침 수용개작)

  • Gu, Mee Ock;Cho, YoungAe;Cho, Myung Sook;Eun, Young;Jeong, Jae Sim;Jung, Ihn Sook;Lee, Young Geun;Kim, Mi Kyung;Kim, Eun Hyun;Kim, Ji Haei;Lee, Sun Hee;Kim, Hyun Lim;Yun, Hee Sook
    • Journal of Korean Clinical Nursing Research
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    • v.19 no.1
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    • pp.128-142
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    • 2013
  • Purpose: This study was conducted to adapt the previously developed intravenous infusion guidelines with good quality for development of the evidence-based intravenous infusion nursing practice guideline in Korea. Methods: Guideline adaptation process was conducted according to guideline adaptation manual version 2.0 developed by NECA (Kim, Kim et al., 2011) which consisted of three main phases, 9 modules including a total of 24 steps. Results: Adapted intravenous infusion nursing practice guideline was consisted of 19 domains and 180 recommendations. The domains and number of recommendations in each domain were: general guide, 4; assessment, 1; vascular access device selection, 4;site selection, 14;site preparation, 5;site care, 29; maintaining patency, 11; blood sampling via vascular access, 4; vascular access device exchange and removal, 9; add-on device selection, 27; infusion related complications, 63; education, 7; and documentation and report, 2. There were 11.9% of A, 28.4% of B, 58.7% of C in grade of recommendations. Conclusion: Adapted intravenous infusion nursing practice guideline is expected to contribute providing an evidence based practice guides for intravenous infusion. The guideline is recommended to be disseminated to nurses nationwide to improve the efficiency of intravenous infusion practice.

Risk Management Standards As a Product Safety Management Program (제품안전경영프로그램으로서의 리스크 관리규격)

  • 이동하
    • Proceedings of the Korean Reliability Society Conference
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    • 2001.06a
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    • pp.376-383
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    • 2001
  • This study reviewed the national standards for risk management to judge whether they are suitable for a product safety management program. Among the standards issued from Australia, New Zealand, Canada, Japan, and UK, the risk management guideline (AS/NZS 4360: 2000) issued jointly from both Australia and New Zealand have better features of product safety management program such as a broad definition of risk concept including opportunities of loss and gain, stepwise composition of processes applicable iteratively, and integrable composition of processes for the existing other management practice. Comparing the three product safety management programs suggested by several authors yielded common features of product safety management program model: (1) organization for product safety, (2) risk identification, (3) risk evaluation, (4) risk treatment, (5) monitoring/communication, and (6) documentation. All of these activities can be performed within risk management framework.

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Usage Characteristics of Publicly-Available Accidental Release Models (주요 누출사고 예측 모델의 사용 특성 비교)

  • 정수희;윤도영;김영성
    • Journal of Korean Society for Atmospheric Environment
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    • v.15 no.5
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    • pp.687-696
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    • 1999
  • Characteristics of four publicly-available accidental release models, ALOHA, SLAB, HGSYSTEM, and DEGADIS, are compared. These models are world-widely used and recently recommended by the Chemical Dispersion and Consequence Assessment(CDCA) Working Group of the United States as models applicable to generally broad safety-basis documentation applicatons. Four release scenarios are assumed by referring to the usage and storage conditions of toxic substances in the field as well as the USEPA model guideline(1993). Sensitivity of impact radius by varying meteorological conditions is tested in typical and worst-case meteorological conditions. The results show that ALOHA generally gives conservative estimates and the results from HGSYSTEM are sensitive to variations in meteorological conditions.

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Strategy for Clinical Progress Note of Physical Therapy (물리치료 임상기록 전략)

  • Bae Sung-Soo;Kim Chung-Sun
    • The Journal of Korean Physical Therapy
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    • v.10 no.2
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    • pp.133-148
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    • 1998
  • Documentation of patient care has much emphasis during the past few years. As reviewing the orthopedic, neurosurgery, rehabilitation medicine of progress note, SOAP note, modified SOAP note and have been integrated a model of Korean clinical progress note of physical therapy. Academically, educationally and clinically development of physical therapy depend upon writing clinical progress note. Based on the research results, the following considerations and guideline are presented. 1. Include writing a clinical progress note of physical therapy in the school curriculums. 2. Physical therapist write the clinical progress note their procedure to the patients. 3. Korean Physical Therapy Association can provide a model of clinical progress note of physical therapy.

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Application of Risk Management Standards for Product Safety Management Program (리스크 관리규격의 제품안전경영프로그램에 대한 적용)

  • 이동하;나윤균;김명수
    • Journal of Applied Reliability
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    • v.1 no.2
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    • pp.109-120
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    • 2001
  • This study reviewed the national standards for risk management to judge whether they are suitable for a product safety management program. Among the standards issued from Australia, New Zealand, Canada, Japan, and UK, the risk management guideline (AS/NZS 4360: 2000) issued jointly from both Australia and New Zealand have better features for product safety management program than any other risk management standards in view point of broad definition of risk concept including opportunities of loss and gain, stepwise composition of management processes applicable iteratively, and integrable form of structure addible to existing management practice. Comparing the three product safety management programs suggested by several authors yielded common features of product safety management program model: (1) organization for product safety, (2) risk identification, (3) risk evaluation, (4) risk treatment, (5) monitoring/communication, and (6) documentation. All of these activities can be performed within risk management framework proposed by AS/NZS 4360.

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A Study on the Level of Medical Record Documentation and Agreement in the Information on the Patient's Past History (과거력 의무기록 정보의 기재정도 및 일치도 분석)

  • Seo, Jung-Sook;Yu, Seung-Hum;Oh, Hyohn-Joo;Kim, Yong-Oock
    • Korea Journal of Hospital Management
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    • v.13 no.1
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    • pp.42-64
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    • 2008
  • This study was conducted to evaluate the quality in medical records by analyzing its completeness through setting up the level of record on the patient's past history and through examining the actual medial records. Targeting the information on the patient's past history in interns' records, residents' records and nurses' records toward 403 inpatients who were admitted first in 2004 at an university hospital due to stomach cancer. We analyzed whether the charts were recorded or not, recording level, the satisfaction with the expectant level of the records in the hospital targeted for a research and the level of agreement. The results were as follows; first, as for the rate of recording those each items, they were high in the chief complaint & present illness and the past illness history. Depending on the group of recorders, the recording rate showed big difference by items. Second, as a result of measuring the level after dividing the recording level of items for the patient's past history from Level 1 to Level 4 by each item, the admission history, the past illness history, and the family history were about Level 3, and the smoking history, the medication history, the chief complaint & present illness, the drinking history and allergy were about Level 2. In the admission department, it was excellent in the interns' records for the medical department. Third, as a result of its satisfactory level by comparing the expect level of a record and the actual record by item in information on the patient's past history, which was expected by the medical-record committee members of the hospital targeted for a study. And forth, we analyzed the level of agreement with Kappa score in the level of 'Yes' or 'None' related to the corresponding matter in Level 1, in terms of information on the past history in the intern's record, the resident's record, and the nurse's record. The level of agreement in the resident's record & the nurse's record, and in the intern's record & the resident's record was from "excellent" to "a little good". There were differences in the level of completeness and in reliability for the information on the past history by the recorder group or by the admission department. The encounter process that was performed by the admission department or the recorder group, indicated the result that was directly reflected on the quality of medical records, thus it was required further study about the medical record documentation process and quality of care. The items that showed the high recording rate quantitatively were rather low, consequently we'd should develop the tool for the qualitative inspection and evaluate the medical records further. And the items were needed to be detailed in the record level were rather low, and hence there needed to be a documentation guideline and education by the clinical departments.

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