• Journal of Korean Academy of Nursing
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• v.29 no.1
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• pp.21-33
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• 1999

This study was designed to develop a basic plan for computerization of nursing records. The subjects were 7 nursing record forms, 58 charts, 23 nurses, 2 nurse managers, a nurse and computer specialist, 16 master course students and 3 professors. Data collection was conducted through questionnaire, observation and interview. The collected data were analyzed for problems, plan of improvement and needs for computerization. Based upon these results, it is recommended that nursing record computerization was needed a basic plan to integrate needs of nursing record computerization. The basic plan as fellows : 1. To illustrate a data flow path of nursing record and data dictionary that show nurse's work and record process. 2. To establish a system in order to use multi -tasking and graphic user interface. 3. To establish hardware and software in order to embody integrated management of computer based system through structured walkthrough. 4. To choose effective database management system and to achieve Log as record unit.

• The Journal of Korean Academic Society of Nursing Education
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• v.27 no.2
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• pp.152-162
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• 2021

Purpose: The purpose of this study was to examine the effect of nursing record education on the knowledge and performance of nursing record of nurses at small- and medium-sized hospitals. Methods: The participants were 62 nurses working in two small- and medium-sized hospitals. Thirty-two nurses comprised the experimental group, and 30 nurses comprised the control group. Nursing record education was provided for the experimental group. Data were analyzed by x²-test and t-test analysis using the IBM SPSS statistics 25.0 Program. Results: After education, the knowledge (t=2.43, p=.019), performance (t=2.19, p=.033) and behavior scores (t=2.42, p=.018) on nursing record were significantly higher in the experimental group than in the control group. Based on this result, nursing record education is an effective intervention to improve nurses' knowledge and performance in writing nursing records in small- and medium-sized hospitals. Conclusion: We suggest the development of a systematic and standardized education program on nursing record including its legal aspects, for nurses in small- and medium-sized hospitals. The results of this study can be used as basic data for developing a nursing record education program for small- and medium-sized hospitals.

• Journal of Korean Academy of Nursing
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• v.7 no.1
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• pp.1-9
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• 1977

Primary function of health record is that as tool of communication between the health processionals with the mutual goal, the promotion of health care standard. Studies have been carried out world over oil tile subject, among those, Weed's Problem-Oriented Health Record is considered a paramount achievement. This study was designed to assess tile possibility of implementing tile problem-oriented health record system through ail experiment in order to provide data for nurse administrators infiltrating reformation of recording system and format. Record of 29 patients admitted at Korea University Hospital, Seoul, from March through June, 1976 for 4 to 14 days were sampled. Nursing notes were recorded by research assistants; senior nursing student trailed extensively by the researcher oil Problem-Oriented Records, oil Problem Oriented Nursing Record format (experimental group) and analysis were carried out comparative, with that of traditional nursing records noted by other nursing personnel (control group) on the same patient. Attitude towards Problem Oriented Nursing Record system and format were attained through questionaries responded by the 51 research assistants. Results are as fellows: Comparative analysis revealed that: 1. Assessment of patients' health problems recorded significantly more in traditional records. 2. Focus of health Problem differed; traditional records slowed significantly higher frequency in medical and procedure as focus while problem oriented records on nursing focus problems. 3. Problem- Oriented records were better organized, Mean value scores of attitude towards Problem- Oriented Records revealed that: Positive value scores on all 4 categories: 1) Assessment of nursing needs, 2) Nursing care planning 3) Patient progress assessment and 4) Tool of teaching and learning revealed that the Problem-Oriented Nursing Record is positively accepted by tile respondents. Recommendation Further experiments on implementation of Problem- Oriented Health Record are recommended: experiment involving all health professionals, in larger scope and longitudinal.

• Journal of Home Health Care Nursing
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• v.10 no.2
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• pp.103-112
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• 2003

Purpose: The purpose of this study was to develope nursing activities record to improve home care nursing for postpartum women following a Cesarean section and newborns. Method: This study for instrument development had three phases: first, selection of nursing activities according to intervention, second, validation of the preliminary home care nursing activities, and third. application of the home care nursing activities. The subjects for validaton were 137 home care nurses and clinical nurses in department of maternity. Result: By Fehring's method, 116 nursing activities according to 19 interventions were included in the preliminary nursing activities record. Among them, 51 critical nursing activities and 65 supporting nursing activities were chosen. During the final process of validation, 121 nursing activities were included. Conclusion: In order to have systemic standardization of this record forms, replication and application in the various home nursing area is need in the future.

• 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.

• Journal of Home Health Care Nursing
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• v.3
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• pp.5-38
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• 1996

The objective of this study is to develope the record forms for the home care nursing. Through the literature review and 4 times of workshop participated with the health practitioner and nursing professors from July 1993 to March 1995, the standands of home nursing care, initial assessment tools, progress notes by diseases and the referral sheet were developed. The Community health practitioner were trained for home nursing care and participated with 5 nursing professors in the workshop to validate the content of the record forms. It is suggested that the more refinement of these record forms fased a defined conceptual framework in the various home nursing area is needed in the future.

• Journal of Korean Academy of Fundamentals of Nursing
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• v.3 no.2
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• pp.273-283
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• 1996

Effectiveness of the video-record learning method in teaching bowel elimination nursing skill was investigated using an experimental research methodology. Data was collected from 63 female students attending Fundamental Nursing class from a nursing college in Seoul. The subjects were randomly assigned to two groups, one is the experimental group of 29 and the other the control group of 34. The independent variable was video-record learning method and the dependent variable were the degree of knowledge achivement, nursing skill achivement, competence on practicing elimination skill, and satisfaction about the learning method. The hypotheses of the study were as following. 1) There will be significant difference between the experimental group and the control group in dependent variables. 2) There will be significant positive correlations between nursing skill achievement and other three dependent variables-interest in nursing, adaptation in nursing, and preference of nursing job. Data was analyzed using descriptive statistics, chi-square test, t-test, and Pearson's correlation coefficient with SPSS $PC^+$ program. Findings of the study are : 1) There was no significant difference between the experimental group and the control group in knowledge achievement using P<.05. 2) There was significant difference between the experimental group and the control group in nursing skill achievement using P<.05. 3) There was no significant difference between the experimental group and the control group in competence on practicing elimination skill using P<.05. 4) There was no significant difference between the experimental group and the control group in satisfaction about learning method using P<.05. 5) There was positive correlation between nursing skill achievement and the other variables but no significant difference was shown. 6) This study suggests that video-record learning method is an effective learning method for achiving basic nursing skills but is not effective in other areas such as knowledge achivement, competence in performing nursing practice, and satis-faction about the learning method. Further study with more developed research design and statistical analysis should be done to investigate the effectivenes of video-record learning method in learning basic nursing skill more accurately.

• 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 Academy of Nursing Administration
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• v.6 no.1
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• pp.55-81
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• 2000

This study examined nursing care in a Newborn Intensive Care Unit (NICU) by reviewing nursing activities for the newborns. Through direct observation, time used for nursing care according to the nursing activity, shift, day of the week, and position of the nurses was measured. This study was done on November 15, 21, 24, 1999 at a university medical center hospital and included eight nurses and 179 newborns as the study subjects. The data were collected from the medical records, and by using a nursing activity record for the NICU, and a nursing activity time record for the NICU. The first step in the data collection process was to develop a list of nursing activities which was done through a literature review, examination of medical affairs and duty records. Content validity was measured by a panel of three professors who were experienced clinicians. In the second step two pre-training sessions were held with three sophomore student nurses who then measured the time for each nursing activity using a stopwatch. The data were analyzed using frequencies for nursing activities, averages, percentages and ANOVA for differences between shift and between days of the week, and percentages and t-test for differences according to position of the nurse. The results are as follows: 1) The total number of activities was 156, direct or indirect nursing activities. Direct nursing activity classified according to physical, educational, emotional/social/economic/spiritual needs. There were 109 direct nursing activities in 16 fields. 2) The order of nursing activities, according to time required, was record keeping, nutritional care, measurement/observation, medication, hygiene care, examination and specimen collection, and checking supplies, and according to frequency, measurement/ examination, record keeping, nutrition care, hygiene care, elimination care and medication. 3) According to shift, direct care during the night shift at 313.4 minutes was the longest time and indirect nursing care during the night shift at 252.2 minutes was the highest time. 4) For days of the week, Monday had the highest time for direct care 275.8 minutes (34.6%) and Wednessday had the highest time for indirect nursing care 269.6 minutes (36.1%). 5) For nursing time according to position of nurse, general nurses had the highest for direct care (330.7 minutes), nurse managers for indirect nursing activities (239.0 minutes) and general nurses for individual private time (63.9 minutes). The results of this study show that the major nursing time consuming activities included record keeping, nutrition care and measurement/examination. For newborns, time needs to be allowed for care to be sensitive, sophisticated and specialized rather than concentrated on indirect nursing tasks such as record keeping. Therefore, it is imperative to develop computerized systems that support a systematic approach to record keeping which is more efficient. Moreover, nursing needs according to shift, day or position of nurse can be utilized in assessing nursing resources through a computerized process.