• 한국병원경영학회지
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• 제15권1호
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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.

• Perspectives in Nursing Science
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• 제5권1호
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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.

• 임상간호연구
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• 제16권3호
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• pp.123-132
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• 2010

Purpose: This study was done to analyse nursing records to identify the nature of pain and actual conditions of pain management in patients hospitalized in one university hospital. Methods: The participants in this study were 783 patients with a length of stay of 3 to 30 days who were discharged from medical wards between June 1 and June 30, 2009. Data on nursing records related to pain management from these patients were reviewed using the Electronic Nursing Records (ENRs) system. Results: Over 30 percent of 10,702 nursing records related to pain assessment had no record on region, severity, nature or frequency of pain. About 30 percent of 13,638 nursing records related to pain intervention showed non-drug pain management techniques. Conclusion: Accurate and complete records on pain assessment including region, severity, nature and frequency of pain are essential to effectively manage patients' pain. Improvement in ENRs system for better assessment and management of pain is required as well as education programs on a standardized measuring tool for both nurses and patients.

• 가정간호학회지
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• 제11권1호
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• pp.14-22
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• 2004

The purpose of this study was to establish the basic-data set for the electronic nursing records system by analysis of nursing phenomenas and nursing actions described in nursing records of orthopedic patients using the ICNP. Nursing notes for 1.421 days of 97 orthopedics patients who were discharged from a tertiary teaching hospital in Daegu were used. Narrative data from the nursing notes were collected. decomposed. and cross mapped with the concepts of the ICNP beta version. In total 11.442 statements were found in the process of decomposing the narrative data into single statement. These statements consist of 3.970(34.70%) nursing phenomena statements. 6.996(61.14%) nursing action statements, and 476(4.16%) other statements. Finally 312 unique statements were collected by integrating same or similar statements. These statements consist of 120 (38.46%) nursing phenomena statements. 154 (49.36%) nursing action statements. and 38 (12.18%) other statements. When this result was cross mapped with ICNP beta version. 77.0% of nursing statements were completely expressed. 17.0% of them were partially expressed. and 0.3% of them were not able to expressed at all. The findings of this study showed the usability of ICNP as terminology of electronic nursing records system. And the result of this study can be utilized for an ICNP-based electronic nursing records system and can help clinical nurses to spend more time on direct nursing.

• 임상간호연구
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• 제15권3호
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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.

• 근관절건강학회지
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• 제26권1호
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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.

• 대한간호학회지
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• 제37권6호
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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.

• Journal of Korean Biological Nursing Science
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• 제25권4호
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• pp.229-242
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• 2023

Purpose: The electronic frailty index (eFI), which is derived from electronic health records, has been recommended as screening tool for frailty due to its accessibility and ease of use. The objective of this systematic review was to identify the prevalence of frailty assessed by the eFI and its influence on health outcomes in older adults with chronic diseases. Methods: We searched PubMed, Embase, Web of Science, CINAHL, SCOPUS, Cochrane, Google search, and nursing journals in Korean from January 2016 to December 2022. Results: Twelve studies were analyzed. The eFI score, based on routine clinical data, was associated with adverse health outcomes. The most frequent outcome studied was mortality, and the eFI was associated with increased mortality in nine studies. Other outcomes studied included hospitalization, length of stay, readmission, and institutionalization in relation to hospital care usage, and cardiovascular events, stroke, GI bleeding, falls, and instrumental activities of daily life as health conditions. Conclusion: Early identification of frailty in older adults with chronic diseases can decrease the burden of disease and adverse health outcomes. The eFI has a good discriminative capacity to identify frail older adults with chronic diseases.

• Journal of information and communication convergence engineering
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• 제18권4호
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• pp.260-266
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• 2020

This study presents the categorical structure for ther epresentation of a 3D human body position system in the WD stage after NP approval by the International Organization for Standardization (ISO), analyzes the needs of electronic medical record users and establishes future implementation plans for expanding its use in Korea. Research was conducted on the needs of doctors, nurses, health and medical information managers, and radiology departments, which are the main stakeholders of electronic medical records. The overall requirements for electronic medical records were derived from the results, and the requirements for each stage of use of electronic medical records were analyzed. Based on the results of the study, the study proposes plans to expand the use of the categorical structure for the representation of the 3D human body position system, and also aims to establish a standard system for health and medical terminology in Korea and contribute to the development of health and medical information standards through international standardization.

• 대한간호학회지
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• 제45권4호
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• pp.523-532
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• 2015

Purpose: The usability, user satisfaction, and impact of electronic nursing record (ENR) systems were investigated. Methods: This mixed-method research was performed as a time-motion (TM) study and a survey which were carried out at six hospitals between August and November 2013. The TM study involved 108 nurses from medical, surgical, and intensive care units at each hospital, plus an additional 48 nurses who served as nonparticipating observers. In the survey, 1879 volunteer nurses completed the Impact of ENR Systems Scale, the System Usability Scale, and a global satisfaction scale. Qualitative and quantitative analyses were performed. Results: The mean scores for the ENR impact, system usability, and satisfaction were 4.28 (out of 6), 58.62 (out of 100), and 74.31 (out of 100), respectively, and they differed significantly between hospitals (F=43.43, p<.001, F=53.08 and p<.001, and F=29.13 and p<.001, respectively). A workflow fragmentation assessment revealed different patterns of ENR system use among the included hospitals. Three user characteristics-educational background, practice period, and experience of using paper records-significantly affected the system usability and satisfaction scores. Conclusion: The system quality varied widely among the ENR systems. The generally low-to-moderate levels of system usability and user satisfaction suggest many opportunities for improvement.