• Korea Journal of Hospital Management
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• v.15 no.1
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• pp.1-12
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• 2010

This study was tried to evaluate the level of completeness and the accordance in electronic medical records by comparing paper-based medical record in doctor's admission records, discharge summary, and nursing information records. Medical records of inpatients of neurology department that the 100 paper-based medical records in 2004 and 100 electronic medical records in 2006 were targeted. Existence of record items and doctor-nurse record accordance were evaluated in doctor's admission record, discharge summary, admission nursing information record, and discharge nursing information record. There were not any differences between electronic medical records and paper-based medical records in doctor's admission record and discharge summary. Electronic medical records had less missing records than paper-based medical records in admission and discharge nursing information records. Electronic medical records showed higher accordance than the paper-based medical record in doctor-nurse record generally, but there were statistically differences in only medication, allergy, smoking, and drinking (p<0.05). In this study, it was verified that the quality of electronic medical records are better than paper-based records in nursing information record and doctor-nurse record agreement.

• The Journal of Korean Academic Society of Nursing Education
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• v.22 no.3
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• pp.396-407
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• 2016

Purpose: This study aimed to identify the effectiveness of educational Electronic Nursing Record System in terms of nursing process preparation ability and satisfaction about the system itself. Methods: A one group pre-post experimental study design was utilized in this study. The effectiveness of the system was examined through quality of nursing diagnoses, interventions, and outcomes and electronic nursing record system satisfaction inventory. Junior and senior nursing students were the potential study respondents and evaluation instruments were applied only for the one who agreed to participated in the study. Education about nursing process and electronic nursing record system was carried out as part of regular classes and students were guided to prepare nursing process upon the scenarios developed earlier. Results: 29 juniors and 33 seniors prepare nursing process documentation related to each scenario and both groups showed significant improvement upon nursing process documentation (t=7.53, p<.001, t=3.23, p=.003, respectively) compared to paper based nursing process preparation. Satisfaction about system itself was 2.78(0.81). Conclusion: Educational electronic nursing record system seems to be effective to train nursing students for nursing process preparation ability. Effort to enhance its utility are called in the area of education and system itself.

• Journal of Korean Clinical Nursing Research
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• v.15 no.3
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• pp.107-116
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• 2009

Purpose: This study was conducted to evaluate the record completeness of the nursing process in the Electronic Nursing Record(ENR) in a university hospital. Methods: We compared nursing statements documented in 2004 with those from the year 2007, given the fact that the ENR system had been utilized since 2004. The ENRs of 35 gastrectomy patients in each year were selected for evaluation. The selected data were 11,822 nursing statements in 2004 and 27,870 in 2007. Results: The number of nursing records which documented the whole nursing process completely was 4,010 (48.3%) in 2007, whereas 513 (5.9%) in 2004 (p<.001). The number of incomplete records in 2004 was 8,142 (94.1%), while 4,300 (51.7%) in 2007 (p<.001). The number of nursing diagnoses was 846 in 2004 and 4,313 in 2007, which increased in number more than 5 times. The most frequently used diagnoses were 'pain', 'risk for infection' and 'risk for ileus' in both years. Conclusion: There was a significant increase in the record completeness on nursing process in 2007 compared to the records in 2004. The reasons for this increase are attributed to nurse training for encouraging to complete recording and nursing record auditing.

• Perspectives in Nursing Science
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• v.5 no.1
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• pp.33-43
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• 2008

Objective: This study explored the reuse of data captured into an electronic nursing record system using the International Classification for Nursing Practice to support nursing research of inpatient's falls. Methods: Risk factors relevant to inpatients falls ;n an acute setting were identified from the literature review. Four risk assessment tools and two risk identification studies were selected. To examine the availability of coded data in an electronic nursing record system for the identified fall fisk factors, we reviewed 11.319 hospital-day records of 118 patients who were reported by the self-report system. Results: We identified 24 fall risk factors of five categories from the literature review, which were used to identify the standard nursing statements addressing fall risks. One hundred thirty five nursing statements were searched from the hospital's nursing data dictionary of statements and were matched with 14 fall fisk factors. Using the 135 statements. we found that mental status, catheter of drip in situ, abnormal gait, insomnia, surgical procedure. and dizziness/vertigo appeared frequently in the nursing records of inpatients with fall s. Also we found 6 risk factors more through the record review. Conclusion: The electronic records would be a good research source for inpatients' falls. Specifically international classification for nursing practice based nursing record system has the potential for promoting clinical researches.

• Journal of Korean Clinical Nursing Research
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• v.16 no.3
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• pp.133-144
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• 2010

Purpose: This study intended to evaluate the intermediate effects of using Electronic Nursing Record System which was introduced 4 years and 4 months ago. Methods: Participants were 65 nurses engaged in 3 shifts in a general hospital. The specific methods were identification of nursing activity times by means of nurses' self-recording in structured forms, survey of user satisfaction using questionnaires, and examination of nurses' responses to open-ended questions about using the system. Results: The direct nursing activities took more than 50% of the time during day and evening shifts. In night shift, direct nursing activities took more than 41% of the time. Comparing to the initial evaluation, measured at 10 months after the introduction, the time spent in indirect nursing activities have decreased about 10% in each shift. The user satisfaction was 3.54 points which was higher than 3.33 points measured at 10 months after the introduction. The nurses recommended some changes needed in the current system to make it better, such as speeding up the system. Conclusion: The intermediate evaluation shows reduced indirect nursing time, increased direct nursing time, and improved user satisfaction.

• Journal of Korean Academy of Nursing
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• v.37 no.6
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• pp.883-890
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• 2007

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.

• Perspectives in Nursing Science
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• v.9 no.2
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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.

• Journal of Korean Clinical Nursing Research
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• v.21 no.3
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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.

• Women's Health Nursing
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• v.17 no.3
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• pp.275-284
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• 2011

Purpose: The purpose of this study was to identify nursing intervention performed by nurses on gynecological nursing units. Methods: The instrument in this study is based on the fifth edition of Nursing Interventions Classification (NIC) (2008). Data was collected by Electronic Medical record from August, 2010 to October, 2010 at one hospital and analyzed by using frequencies in the Microsoft Excel 2010 program. Results: Of a total of 82 NIC, domains of the nursing interventions showed higher percentages for physiological: basic (36.3%) and physiological: complex (34.5%). The classes of nursing interventions showed higher percentage for health system medication (12.1%), perioperative care (10.0%), and drug management (8.6%). The most frequently used top interventions were Discharge Planning. The thirty least used interventions was environmental management. Top thirty most frequently used interventions belonged to the domain of physiological: basic (37.9%), physiological: complex (31.1%), and behavioral (5.4%). Conclusion: These findings will help in the establishment of a standardized language for gynecological nursing units and enhance the quality of nursing care.

• Journal of muscle and joint health
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• v.26 no.1
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• pp.27-34
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• 2019

Purpose: This study was done to analyze nursing assessment and nursing care for pain in the electronic nursing records for the elderly patients with abdominal pain visiting the Emergency Medical Center. Methods: This study is a descriptive study based on nursing records from January to December 2015. A total of 1155 records for elderly patients with abdominal pain were gathered. Results: The mean age of elderly patients whose records were analyzed was 75.2 years. Analysis of nursing records regarding pain management showed that semi-urgent severity (93.7%), direct emergency room visits (58%), and 6.01 hours of emergency room stay (6.01 hours)were the most frequently documented characteristics of the elderly patients with pain complaints. Recording time of nursing assessment for abdominal patients was 1.01 hour; the average pain intensity was 3.97. The mostly used nursing intervention for abdominal pain was medication (65.1%). There was no record of non-pharmacological pain nursing interventions. Conclusion: The results of this study showed that improving knowledge and nursing practice for pain management is much of necessity. In particular, development of the non-pharmacological nursing interventions for pain is needed. Further research is also imperative to develop and evaluate record systems for pain management that can be used in the emergency room.