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최귀윤 ( Choi Gui-Yun ) - 울산대학교 간호대학
문영숙 ( Moon Young-Sook ) - 울산대학교병원 응급의학과
홍은석 ( Hong Eun-Seog ) - 울산대학교병원 응급의학과
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Abstract
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Purpose: The purposes of this study were to investigate medical records and to develop care records for management of patients with chest pain in the emergency department.
Method: Retrospective review of the 42 medical chart of patients presented to the emergency department with chest pain were used. The collected data were analyzed with a frequency of items in the medical records.
Results: In a frequency analysis of recorded items for doctors’ chest pain assessment during history taking, the history/risk factors was the highest rank. The following ranks were ’commenced with when/ timing, extra symptoms, place, nature, stay/ radiate, alleviate/aggravate, intensity’ in sequence. In a frequency of recorded items in nurse’s progress notes according to nursing actions, the ’checking/monitoring’ was the highest rank. The following ranks were ’performing, administering/injecting, referring/ arranging, testing, preparing/catheterizing, teaching/informing’ in sequence. Chest pain care records for the emergency department was designed, based upon data analysis and literature review.
Conclusion: The designed records can be a rapid and effective approach tool for assessment and recording of patients with chest pain. Further research is necessary for evaluating the designed chest pain care records.
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KeyWords
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응급, 흉통, 간호 기록지
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원문 및 링크아웃 정보
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등재저널 정보
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