• Journal of Korean Academy of Fundamentals of Nursing
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• v.13 no.1
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• pp.24-32
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• 2006

Purpose: This study was a comparative review of the computerized nursing records and paper-based nursing records to examine effects of a nursing process documentation system focusing on patients who have had stroke. Method: First, the researchers collected all the foci from the computerized records and the paper-based records. They selected ten nursing foci, used frequently in both groups and analyzed the number of foci per patient, appropriateness of foci, the number of nursing activities per nursing focus and whether outcomes were described or not in the nursing record. Results: There was fewer errors in nursing diagnosis selection, and a larger number of activities in the records than trle paper based ones. Also, there was a better description of the nursing outcomes in the computerized records. Conclusion: This study suggests that the computerized nursing records is significantly effective in increasing accuracy of the nursing care plan and quality of the nursing record.

• 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.

• Journal of Korean Academy of Nursing Administration
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• v.8 no.3
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• pp.411-430
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• 2002

Purpose : This study was to develop Nursing Process Model of abdominal surgery patient using nursing diagnoses of NANDA, Nursing Interventions Classification(NIC), and Nursing Outcomes Classification(NOC). Method : The data in database were collected from nursing records in sixty patients with abdominal surgery admitted in a university hospital and open questionnaires of thirteen nurses. Systematic nursing process resulting from each nursing diagnoses, most common, was developed by the statistical analysis through database query from clinical database of abdominal surgery patients. Result : 51 nursing diagnoses were identified in abdominal surgery patients. The most commonly occurred nursing diagnoses were Pain, Risk for Infection, Sleep Pattern Disturbance, Hyperthermia, Altered Nutrition: Less Than Body Requirements in order. The linkage lists of NANDA to NIC and NANDA to NOC, and the nursing activities according to nursing diagnoses of abdominal surgery patients were identified in unit. Conclusion : Nursing Process of abdominal surgery patients was comprised of core nursing diagnoses, core nursing interventions, core nursing outcomes which provides the most reliable data in unit and could make nurses facilitate nursing process easily without full consideration of knowledge about nursing language classification system. Therefore, it could support nurses' decision making and recording of nursing process especially in the computerized patient record system if unit nursing process model using standardized nursing language system which contains of their own core nursing process data was developed.

• Journal of Intelligence and Information Systems
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• v.16 no.2
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• pp.73-94
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• 2010

The attending system is a medical system that allows doctors in clinics to use the extra equipment in hospitals-beds, laboratory, operating room, etc-for their patient's care under a contract between the doctors and hospitals. Therefore, the system is very beneficial in terms of the efficiency of the usage of medical resources. However, it is necessary to develop a strong support system to strengthen its weaknesses and supplement its merits. If doctors use hospital beds under the attending system of hospitals, they would be able to check a patient's condition often and provide them with nursing care services. However, the current attending system lacks delivery and assistance support. Thus, for the successful performance of the attending system, a networking system should be developed to facilitate communication between the doctors and nurses. In particular, the nursing records in the attending system could help doctors monitor the patient's condition and provision of nursing care services. A nursing record is the formal documentation associated with nursing care. It is merely a data repository that helps nurses to track their activities; nursing records thus represent a resource of primary information that can be reused. In order to maximize their usefulness, nursing records have been introduced as part of computerized patient records. However, nursing records are internal data that are not disclosed by hospitals. Moreover, the lack of standardization of the record list makes it difficult to share nursing records. Under the attending system, nurses would want to minimize the amount of effort they have to put in for the maintenance of additional records. Hence, they would try to maintain the current level of nursing records in the form of record lists and record attributes, while doctors would require more detailed and real-time information about their patients in order to monitor their condition. Therefore, this study developed a system for assisting in the maintenance and sharing of the nursing records under the attending system. In contrast to previous research on the functionality of computer-based nursing records, we have emphasized the practical usefulness of nursing records from the viewpoint of the actual implementation of the attending system. We suggested that nurses could design a nursing record dictionary for their convenience, and that doctors and nurses could confirm the definitions that they looked up in the dictionary through negotiations with intelligent agents. Such an agent-based system could facilitate networking among medical institutes. Multi-agent systems are a widely accepted paradigm for the distribution and sharing of computation workloads in the scientific community. Agent-based systems have been developed with differences in functional cooperation, coordination, and negotiation. To increase such communication, a framework for a multi-agent based system is proposed in this study. The agent-based approach is useful for developing a system that promotes trade-offs between transactions involving multiple attributes. A brief summary of our contributions follows. First, we propose an efficient and accurate utility representation and acquisition mechanism based on a preference scale while minimizing user interactions with the agent. Trade-offs between various transaction attributes can also be easily computed. Second, by providing a multi-attribute negotiation framework based on the attribute utility evaluation mechanism, we allow both the doctors in charge and nurses to negotiate over various transaction attributes in the nursing record lists that are defined by the latter. Third, we have designed the architecture of the nursing record management server and a system of agents that provides support to the doctors and nurses with regard to the framework and mechanisms proposed above. A formal protocol has also been developed to create and control the communication required for negotiations. We verified the realization of the system by developing a web-based prototype. The system was implemented using ASP and IIS5.1.

• Journal of Korean Academy of Fundamentals of Nursing
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• v.7 no.1
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• pp.97-108
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• 2000

The purpose of this study was to assess the present status of the course content of Fundamental Nursing in accordance with the study objectives which were developed for the National Qualifying Examination by the first Faculty-Workshop in January, 1999 and the study objectives as related to other Nursing courses. The study sample included all schools of nursing and the members of the faculty for Fundamental Nursing of seventy schools(66.7%), out of the target population of 105, responded to a questionnaire which was developed by the research team. The collected data were analyzed by frequencies, percentages, means, and standard deviation using the SAS(Statistical Analysis System). The results are as follows : 1) According to this survey the course content of Fundamental Nursing as described in the study objectives for the National Examination, 223(86.77%) study objectives were included in the course of Fundamental Nursing by more than 70% of the schools of nursing, But twenty-three of the study objectives are not included by $30{\sim}50%$ of the schools of nursing. They consider this content to be taught in other courses. The study objectives, which less than 50% of the schools reported as being included in their course in Fundamental Nursing were, all study objectives for 'nursing assessment(communication)', 'nursing assessment (physical examination)', 'record and report', 'sex', and 'use of computer program for nursing diagnosis' and 'use of computerized nursing planning program' 2) Items that were not included in the study objectives for Fundamental Nursing but were included in course content for over 50% of the schools included, 'health of individual, family, community', 'change of nursing practice'. 'professionality of nursing' and all of the study objectives belonging to 'loss and grief' and 'nursing during all stages of surgical operations'. We hope that these results will be helpful in modifying the study objectives for the National Examination as developed by the first Faculty-Workshop and recommend the need for continuous survey research to produce content that is in accordance with study objectives and a National Examination that reflects the content of Fundamental Nursing.

• Journal of radiological science and technology
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• v.28 no.4
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• pp.307-315
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• 2005

In the ubiquitous computing environments, ICT industries of current society are developed in enormous growth. Medicine or patients with mobile devices can access at any time, any place. The medical procedures at the patient bedside are out of the scope of current systems, which means that patient record and image data access during the medical visit or the execution, recording and confirmation of the medicine prescriptions, still do not enjoy computerized support. Today, the exchange of medical images and clinical information is well defined by DICOM and HL7 standards. The DICOM independent terminal equipment image access system was developed in which a DICOM Engine acts as the gateway between a PACS DB and user's terminal. Implementation system is compatible with most currently available Integration system models. This paper presents a software technology where the medical and nursing staff will be equipped with any device connected by wire and wireless to a central server that provides access to the electronic patient records and that will actively inform about tasks pending distribution. The prototype described in this article implements a medical images and structured reports server that makes the search and recovery of data stored in the DICOM standard possible.