• Title/Summary/Keyword: Nursing record forms

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A Study on the Development of the Record forms for the Home Care Nursing (가정간호기록지 개발에 관한 연구)

  • Han, Kyung-Ja;Park, Sung-Ae;Hah, Yang-Sook;Yun, Soon-Nyoung;Song, Mi-Soon
    • 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.

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Development of the Nursing Record Forms for Effective Home Care Nursing -Focused on Postpartum Women following a Cesarean Section and Newborns- (가정간호업무 효율성을 위한 간호활동 기록도구 개발 -제왕절개 산욕부와 신생아를 중심으로-)

  • HwangBo, Su-Ja;Yang, Jin-Hyang
    • 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.

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A Basie Study on Improvement and Computerization of Nursing Record (간호기록의 개선과 전산화를 위한 기초연구)

  • 지성애;최경숙;박경숙;정용기
    • 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.

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Development of Records for Home Hospice Care Team (기정 호스피스 팀 기록지 개발)

  • Lee, Jong-Eun;Han, Sung-Suk;Park, Chai-Soon;Yoo, Yang-Sook;Choe, Sang-Ok;Lee, Mi-Song;Kim, Seong-Eun;Lee, Sun-Mi
    • Journal of Hospice and Palliative Care
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    • v.11 no.1
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    • pp.12-29
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    • 2008
  • Purpose: To develop the standardized record forms for home hospice team members, made up of nurse, doctor, social worker, minister and volunteer, to share information and communicate efficiently in their specialized field. Methods: A methodological study revising and complementing initially developed record forms by obtaining content validity from the experts in each field. Results: Reflecting total 27 experts' opinions, final 11 types of home hospice team documents (registration form, visiting record form for a nurse, initial assessment form for a doctor, progress note for a doctor, initial assessment form for spiritual care, visiting record form for a minister, care note for social worker, visiting record form for a volunteer, final summary note, initial assessment form for bereaved family, and follow-up record form for bereaved family) have been developed. Conclusion: It is believed that this study initiated of effective communication between home hospice team members and enhanced quality of home hospice service and its records.

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Intermediate Evaluation after the Introduction of Electronic Nursing Record System in a General Hospital (일개 종합병원 전자간호기록시스템 도입 후 중기 평가연구)

  • Kim, Doh Yeon;Park, Myong Hwa
    • 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.

Development of a Home Care Nursing Management System for Computerization of Home Care Nursing Practice (가정간호업무 전산화를 위한 가정간호관리 시스템 개발)

  • Yoo, Ji-Soo;Kim, Cho-Ja;Shin, Hye-Sun;Choi, Hee-Jai
    • Journal of Home Health Care Nursing
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    • v.8 no.1
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    • pp.62-73
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    • 2001
  • This study was conducted to develop a home care nursing management system based on the validated and useful data base found through literature review. The contents and structure according to a development procedure for a computer system were as follows. 1. A data base on home care nursing patients was accumulated by putting data respectively in both steps and fields - from selection criteria. basic information. prescription. plan of home visits. to application of nursing process. 2. Accumulated data was classified and designed to search by basic information. drug/injection prescription. examination prescription, treatment prescription. supply. and a record of the nursing process. 3. Various forms of retrieval including graphs were elaborated in terms of diagnosis and intervention aspects.

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Japanese Nursing Students' Learning Experience, Self-directed Learning Ability, and Self-efficacy in Nursing Practice Utilizing Portfolios (일본 간호학생의 학습포트폴리오를 활용한 임상실습교육의 학습경험과 자기주도학습능력 및 자기효능감)

  • Lee, Hye Young;Shimotakahara, Rie;Kim, Hye Weon;Ogata, Shige Mitsu
    • The Journal of Korean Academic Society of Nursing Education
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    • v.23 no.3
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    • pp.279-289
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    • 2017
  • Purpose: The purpose of this study is to investigate the learning experience, self-directed learning ability and self-efficacy of Japanese nursing students undergoing portfolio-based clinical practicums. Methods: The self-directed learning ability and self-efficacy of nursing students were examined using two scales. And using a text-mining approach, we constructed correspondence analysis followed by cluster analysis of open-ended responses forms. Results: The mean score of the self-directed learning ability was $60.89{\pm}5.28$ and the generalized self-efficacy was $68.37{\pm}11.56$. Moreover, the scores in the self-directed learning ability were positively correlated with scores in the generalized self-efficacy. In correspondence analysis, the distribution of extracted words showed that record was located on the negative side of the third quadrant, to the first principal component and that patient was located on the positive side of the first quadrant, contributing greatly to the second principal component. Conclusion: The results of this study contribute to approaching to "confidence, pride, stability," "growth and intention to development'' offers a key in developing self-directed learning ability. Students record what they see and learn the importance of visualizing it in learning portfolios. "Expression in detail of the learned contents" and "concerning to which objective evaluation is suggested" are important to the students.

Development of Health Assessment Tools and Tailored Home Visiting Nursing Service Model for Children in Poverty (신생아-학령전기 대상자의 맞춤형 방문건강관리 기록지 및 모형 개발)

  • Kim, Hee-Ja;Yoo, Jae-Soon;Kim, Hyun-Sook;Tak, Yang-Ju;Bang, Kyung-Sook;Huh, Bo-Yun
    • Korean Parent-Child Health Journal
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    • v.13 no.2
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    • pp.63-77
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    • 2010
  • Purpose: The purpose of this study was to develop child's health assessment tools and tailored home visiting nursing service model in a community. Methods: Based on the literature review and several types of workshops participated with the child health nursing professors and visiting nurses in public health centers from May to December 2009, the standards of child health assessment tools, service model and education materials for visiting nurses were developed. Results: Some record forms were newly developed, including neonatal assessment, breast feeding, mother-infant interaction, oral care, vaccination and safety, and appropriate developmental screening tests in the community were selected. For systematic health care management in the community, problem list, problem criteria, health care plan, outcome criteria were also developed. Conclusion: On the demand of growing need for health promotion and early intervention for children and their association with parenting and socioeconomic status, assessment and control measures are indispensable to the promotion of child health for vulnerable population. Children's health and developmental problems, and safe circumstances can be assessed using this assessment tools, and can be used for tailored home visiting nursing care for children.

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The Lived Experiences of Patient's Families with the Intensive Care Unit Diary (환자 가족의 중환자실 일기 체험)

  • Jeong, Yu Jin;Ryoo, Sung Suk;Shin, Hyun Jeong;Yi, Young Hee
    • Journal of Korean Critical Care Nursing
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    • v.16 no.1
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    • pp.28-43
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    • 2023
  • Purpose : Intensive care unit (ICU) diaries have been implemented across the international ICU community. This study aimed to comprehend the meaning and nature of the lived experience of patients' families using the ICU diary in Korea. Methods : This qualitative study adopted van Manen's hermeneutic phenomenology. The participants comprised eight women and two men who were the family members of patients in the ICU for more than three days. Data were collected using in-depth interviews and observation from July 2018 to January 2019. Results : Patients' families who experienced the ICU diary recognized it with six beings according to time: a good idea, forgotten stuff, burdensome work, touching service, my stuff, and a thing in the memory. The ICU diary had three essential meanings for the families: communication, solace and hope, and a record of life. These findings were rearranged according to van Manen's fundamental existential, and the lived things and lived others were remarkably confirmed. Conclusion : Patients' families experienced various ICU diary forms over time and recognized an ICU diary as a means of communication. Therefore, the ICU diary is expected to be used as an intervention between families and healthcare providers in the ICU to support mutual communication.

A Study on the Development of Children's Health Assessment Tools in Child Care Centers (보육시설 영유아의 건강사정을 위한 기록지 개발)

  • Han, Kyung-Ja;Bang, Kyung-Sook;Kwon, Mi-Kyung;Kim, Ji-Soo;Choi, Mi-Young;Huh, Bo-Yun
    • Korean Parent-Child Health Journal
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    • v.12 no.1
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    • pp.61-76
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    • 2009
  • Purpose: The purpose of this study was to develop child's health assessment tools for children in child care centers. Methods: Based on the literature review and several types of workshops participated with the child health nursing professors, doctoral students, nurses in pediatric units and pediatric psychiatric units from July to December 2006, the standards of child health assessment tools were developed. Graduate students and 4th grade students in nursing were trained for health assessment and used these assessment tools to validate the content and reliability of said tools. Results: Some record forms were newly developed, including demographic characteristics, past history, present health status, behavioral problems, and appropriate developmental screening tests in child care centers were selected. For systematic health care management in child care centers, daily care report, illness log, and referral sheet were also developed. Conclusion: In the face of growing utilization of daycare and their association with increased risk of various diseases, assessment and control measures are indispensable to the promotion of child health. Children's physical and mental health and developmental problems can be assessed using this assessment tools. They can be used for establishing the direction for developing a health care service system for young children.

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