• Title/Summary/Keyword: Electronic nursing records

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Shortening of Nursing Record Time about Real Time Transmission Effect of Blood Pressure, Blood Glucose Value Based on U-Healthcare (유-헬스케어 기반 실시간 혈압, 혈당 측정치 전송의 간호기록 시간 단축)

  • Park, Jeong-Eun;Kim, Hwa-Sun;Hong, Hae-Sook
    • Journal of Korean Biological Nursing Science
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    • v.15 no.4
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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.

Cardiovascular Risk Factors Predicting Endothelial Dysfunction in Patients with Variant Angina (이형협심증 환자의 혈관내피세포 기능저하에 영향을 미치는 심혈관질환 위험인자)

  • Cho, Sook-Hee;Hwang, Seon-Young;Jeong, Myung-Ho
    • Korean Journal of Adult Nursing
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    • v.21 no.5
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    • pp.477-488
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    • 2009
  • Purpose: This study was conducted to identify the clinical characteristics and risk factors on the occurrence of variant angina, and to examine the predicting factors on the vascular endothelial dysfunction of the patients with variant angina. Methods: A total of 134 patients diagnosed with variant angina were recruited from 2006 to 2008. The degrees of endothelial dysfunction were measured and recorded by the researcher using the values of flow-mediated vasodilation of their brachial arteries and Nitroglycerine-mediated dilation. Subjects' demographic data and risk factors were gathered after obtaining informed consent, and their electronic medical records were reviewed to collect laboratory data. Results: The mean age was $54.2{\pm}9.6$ years and 52% was male patients. More than 50% of the male patients were cigarette smokers and had hypercholesterolemia. 84% of the male patients and 70% of the female patients had more than one risk factor of cardiovascular disease. A stepwise multiple regression analysis showed that smoking and hypercholesterolemia predicted the decrease of flow-mediated vasodilation (Adjusted $R^2$ = .204, p < .001). Conclusion: Tailored educational interventions for smoking cessation and cholesterol management are needed to prevent recurrence of angina attack for patients with variant angina and to prevent cardiovascular disease for middle-aged workers.

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Validation of Fall Risk Assessment Scales among Hospitalized Patients in South Korea using Retrospective Data Analysis (후향적 자료분석을 통한 낙상위험 사정도구의 타당도 비교: 종합병원 입원 환자를 중심으로)

  • Kang, Young Ok;Song, Rhayun
    • Korean Journal of Adult Nursing
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    • v.27 no.1
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    • pp.29-38
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    • 2015
  • Purpose: The purpose of the study was to validate fall risk assessment scales among hospitalized adult patients in South Korea using the electronic medical records by comparing sensitivity, specificity, positive predictive values, and negative predictive values of Morse Fall Scale (MFS), Bobath Memorial Hospital Fall Risk Assessment Scale (BMFRAS), and Johns Hopkins Hospital Fall Risk Assessment tool (JHFRAT). Methods: A total of 120 patients who experienced fall episodes during their hospitalization from June 2010 to December 2013 was categorized into the fall group. Another 120 patients, who didn't experience fall episodes with age, sex, clinical departments, and the type of wards matched with the fall group, were categorized to the comparison group. Data were analyzed for the comparisons of sensitivity, specificity, positive and negative predictive values, and the area under the curve of the three tools. Results: MFS at a cut-off score of 48 had .806 for ROC curves, 76.7% for sensitivity, 77.5% for specificity, 77.3% for positive predictive value, and 76.9% for negative predictive value, which were the highest values among the three fall assessment scales. Conclusion: The MFS with the highest score and the highest discrimination was evaluated to be suitable and reasonable for predicting falls of inpatients in med-surg units of university hospitals.

Characteristics and Mortality Risk Factors in Geriatric Hospital Patients visiting One Region-wide Emergency Department (일 권역응급의료센터를 방문하는 요양병원 환자들의 특성 및 사망 위험요인)

  • Kim, Kyoung Wan;Jang, Soongnang
    • Research in Community and Public Health Nursing
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    • v.27 no.4
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    • pp.327-336
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    • 2016
  • Purpose: This study was to examine the clinical characteristics and mortality risk factors of geriatric hospital patients who visited one region-wide emergency department (ED). It's basically meant to develop criteria for the patient management of geriatric hospitals and to provide related information. Methods: A retrospective research study was implemented using electronic medical records. The subjects in this study included 484 geriatric hospital patients who were selected from among 15,994 patients that visited one region-wide ED between January 1, 2014, and December 31, 2015. Results: There were significant differences in death, a change for the better and no change for the better, which were results of treatment, according to the length of stay in hospital, hospitalization in a general ward, not having an operation or surgery, the presence or absence of malignant neoplasm, the insertion of foley catheter, intubation, ventilator and the insertion of central venous catheter. Conclusion: The results of this study suggest that a patient management system is necessary in geriatric hospitals and that competent healthcare workers who can properly respond to emergencies are required as well.

Characteristics of Burn Types, Causes, and Treatment in Hospitalized Female Patients with Industrial Injuries (화상으로 입원한 여성 근로자의 화상유형 및 발생원인, 치료적 특성)

  • Kim, Ji-Na;Kang, Hee Sun
    • Korean Journal of Occupational Health Nursing
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    • v.25 no.2
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    • pp.85-95
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    • 2016
  • Purpose: The purpose of this study was to examine the burn characteristics of female patients hospitalized in a burn center. Methods: This is a retrospective descriptive study. The subjects were 222 female patients aged over 19 years old having burn injuries from work sites between January 1, 2012 and December 31, 2014. Data were collected using electronic medical records about the burn-related characteristics. The data were analyzed descriptively. Results: Many of the subjects were in their forties and fifties. Most subjects showed burns with an area of less than 10% of the body surface with a severity of second degree. Scalding burns were the most frequent. Contact burns were usually of third-degree severity and occurred on hands and wrists. Flame burns affected the largest body surface area and frequently occurred on the face and mainly caused by explosion of a stove or kitchen gas. Chemical burns frequently occurred on the lower limbs. Conclusion: Female workers are exposed to the hazards of burn injuries in industrial accidents. Types of burn differ depending on the workplace conditions. Therefore, preventative measures for burn injuries should be established in accordance with the characteristics of each industry to which female workers belong.

Risk Factors of Unplanned Readmission to Intensive Care Unit (중환자실 환자의 비계획적 재입실 위험 요인)

  • Kim, Yu Jeong;Kim, Keum Soon
    • Journal of Korean Clinical Nursing Research
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    • v.19 no.2
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    • pp.265-274
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    • 2013
  • Purpose: The aim of this study was to determine the risk factors contributed to unplanned readmission to intensive care unit (ICU) and to investigate the prediction model of unplanned readmission. Methods: We retrospectively reviewed the electronic medical records which included the data of 3,903 patients who had discharged from ICUs in a university hospital in Seoul from January 2011 to April 2012. Results: The unplanned readmission rate was 4.8% (n=186). The nine variables were significantly different between the unplanned readmission and no readmission groups: age, clinical department, length of stay at 1st ICU, operation, use of ventilator during 24 hours a day, APACHE II score at ICU admission and discharge, direct nursing care hours and Glasgow coma scale total score at 1st ICU discharge. The clinical department, length of stay at 1st ICU, operation and APACHE II score at ICU admission were the significant predictors of unplanned ICU readmission. The predictive model's area under the curve was .802 (p<.001). Conclusion: We identified the risk factors and the prediction model associated with unplanned ICU readmission. Better patient assessment tools and knowledge about risk factors could contribute to reduce unplanned ICU readmission rate and mortality.

Validation of the Edmonson Psychiatric Fall Risk Assessment Tool for Psychiatric Inpatients: A Retrospective Study (정신건강의학과 입원 환자를 위한 낙상 위험 사정도구 (Edmonson Psychiatric Fall Risk Assessment Tool)의 타당도 평가: 후향적 연구)

  • Kim, Kyung Young;Son, Young Sun;Lee, You Ji;Kim, Ji Eun;Kim, Mi Kyung;YI, Young Hee
    • Journal of Korean Clinical Nursing Research
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    • v.28 no.3
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    • pp.270-276
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    • 2022
  • Purpose: The purpose of this study was to validate the Edmonson psychiatric fall risk assessment tool (EPFRAT) for psychiatric inpatients. Methods: Data from retrospective study were collected from 670 adult inpatients in two departments of mental health medicine of a tertiary general hospital by reviewing their electronic medical records. There were 41 patients who experienced falls and 629 patients who did not experience falls during the period from January to December 2019. Data were analyzed by sensitivity, specificity, positive predictive value, negative predictive value, and a receiver-operating characteristic curve (ROC) for validity assessment using the IBM SPSS/WIN 26.0 program. Results: Factors affecting falls were the participant's age, guardian's residence, high-risk determination at the time of admission, and comorbidity. At the 85 points where the point of sum of the sensitivity and specificity was largest, the sensitivity, specificity, positive predictive value, and negative predictive value of EPFRAT were 92.7%, 79.7%, 22.9%, and 99.4%, respectively. The area under the ROC to assess the overall validity of the tool was .92 (95% CI 0.89~0.94). Conclusion: The EPFRAT was proved to be valid and reasonable for predicting falls in psychiatric inpatients. Based on the results of this study, it could be used for the assessment of high-risk patients for falls in psychiatric units.

Perception and Performance about Patients' Medical Information Protection in Allied Health College Students (보건계열 대학생의 환자 의료 정보 보호에 대한 인식과 수행)

  • Choi, Seon Young;Lim, Do Yeon;Ko, Il Sun;Moon, In Oh
    • The Journal of Korean Academic Society of Nursing Education
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    • v.22 no.1
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    • pp.83-95
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    • 2016
  • Purpose: This study aims to identify perception, performance, and the related factors of performance in regards to patients' medical information protection among allied health college students. Methods: Four hundred twelve subjects from three colleges located in Jeonbuk and Kyungbuk province consented to participate. Data was collected from November 28 to December 15, 2012. To assess perception and performance in regards to patients' medical information protection, a self-reporting questionnaire was used. Data was analyzed via SPSS 18.0 program. Results: The score of perception and performance about patients' medical information protection were 4.07 and 3.56, respectively. All item's scores of performance were significantly lower than those of perception. The perception score was significantly different according to recognition of hospital ethics code (t=1.95, p=.052), and recognition of association ethics code (t=2.88, p=.004). The performance score was significantly different according to gender (t=-3.32, p=001), major (F=14.41, p<.001), clinical practicum hospitals (F=8.22, p<.001), and method of electronic medical record access (F=3.23, p=.023). The factors influencing performance were perception(${\beta}=.46$, p<.001), duration of clinical practice(${\beta}=-.36$, p<.001), and gender(${\beta}=.09$, p=.033). Conclusion: In order to improve performance in regards to patients' medical information protection of allied health college students, we should develop ethical education programs and standardize them through multidisciplinary collaboration.

Factors Affecting the Postoperative Pain and Length of Hospital Stay of Liver Transplantation Donors (간이식 공여자의 수술 후 통증 특성 및 재원기간에 대한 영향 요인)

  • Jung, Je Hyun;Bang, Kyung-Sook
    • The Journal of Korean Academic Society of Nursing Education
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    • v.24 no.4
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    • pp.433-442
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    • 2018
  • Purpose: This study was performed to investigate the factors affecting postoperative pain and length of hospital stay of liver transplantation donors. Methods: This is a retrospective study using the Electronic Medical Records (EMR) of 91 patients operated on at a tertiary hospital in Seoul, Korea in 2016. The collected data were analyzed using descriptive statistics, t-test, Mann-Whitney U test and Kruskal-Wallis test, Spearman's rank correlation, and multiple regression analysis. Results: The average age of the donors was $35.7{\pm}12.2$ years, and all donors were family members. PCA was applied for control pain in all patients, and 40.7% of PCA-related side effects were observed. The average length of hospital stay was $9.24{\pm}2.52$ days. The factors influencing the length of hospital stay were operative methods, pain control methods, and postoperative complications. The length of hospital stay was 1.29 days shorter if donors had no complication, 1.43 days shorter when only PCA was used, and 1.19 days shorter when laparoscopic resection was performed (Adjusted $R^2=0.17$, F=4.67, p<.05). Conclusion: The results of this study can be used as basic data for practical and effective postoperative nursing education and intervention of living liver donors.

Development of a Diabetic Foot Ulceration Prediction Model and Nomogram (당뇨병성 발궤양 발생 위험 예측모형과 노모그램 개발)

  • Lee, Eun Joo;Jeong, Ihn Sook;Woo, Seung Hun;Jung, Hyuk Jae;Han, Eun Jin;Kang, Chang Wan;Hyun, Sookyung
    • Journal of Korean Academy of Nursing
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    • v.51 no.3
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    • pp.280-293
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    • 2021
  • Purpose: This study aimed to identify the risk factors for diabetic foot ulceration (DFU) to develop and evaluate the performance of a DFU prediction model and nomogram among people with diabetes mellitus (DM). Methods: This unmatched case-control study was conducted with 379 adult patients (118 patients with DM and 261 controls) from four general hospitals in South Korea. Data were collected through a structured questionnaire, foot examination, and review of patients' electronic health records. Multiple logistic regression analysis was performed to build the DFU prediction model and nomogram. Further, their performance was analyzed using the Lemeshow-Hosmer test, concordance statistic (C-statistic), and sensitivity/specificity analyses in training and test samples. Results: The prediction model was based on risk factors including previous foot ulcer or amputation, peripheral vascular disease, peripheral neuropathy, current smoking, and chronic kidney disease. The calibration of the DFU nomogram was appropriate (χ2 = 5.85, p = .321). The C-statistic of the DFU nomogram was .95 (95% confidence interval .93~.97) for both the training and test samples. For clinical usefulness, the sensitivity and specificity obtained were 88.5% and 85.7%, respectively at 110 points in the training sample. The performance of the nomogram was better in male patients or those having DM for more than 10 years. Conclusion: The nomogram of the DFU prediction model shows good performance, and is thereby recommended for monitoring the risk of DFU and preventing the occurrence of DFU in people with DM.