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백승연 ( Baik Seung-Yeon ) - 연세대학교의료원 세브란스병원
조은희 ( Cho Eun-Hee ) - 연세대학교 간호대학
김영아 ( Kim Young-Ah ) - 연세대학교 의료원 의료정보실
최모나 ( Choi Mo-Na ) - 연세대학교 간호대학
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Abstract
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Purpose: This study aimed to identify the type and frequency of nursing activities targeting emergency department patients by analyzing electronic nursing records.
Methods: This retrospective study identified the characteristics of and nursing activities for adult patients who visited a university hospital emergency department for 6 months from January to June 2018 by analyzing the hospital’s electronic nursing records. Descriptive statistics and one-way analysis of variance were used to analyze the characteristics of patients and the nursing records.
Results: A total of 36,435 patients, with an average age of 52.82±19.91 years and a male-to-female ratio of 1:1.16, participated in the study. The number of patients with Korean Triage and Acuity Scale levels 4 (less urgent) and 5 (non-urgent) were 24,403 (67% of the total number). Referrals were requested 1.21±0.54 times per patient. The most frequent NANDA diagnosis and Nursing Intervention Classification intervention were “Risk for unstable blood glucose level” (858, 28.4%), and “Surveillance” (83,131, 23.9%). The most frequent Clinical Care Classification action type was “Assess or Monitor” (313,729, 38.5%). The higher the severity level and the number of referrals, the more the recorded numbers of nursing diagnoses, interventions, and care activities.
Conclusion: This study demonstrated the possibility of nursing task analysis by identifying the type and frequency of nursing activities based on the data from electronic nursing records. Further research on electronic nursing records would contribute to the usefulness of these records for nursing workload analysis and effective workforce management.
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KeyWords
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응급실, 전자의무기록, 간호업무, 한국형 응급 환자 분류도구(KTAS), 협의진료
Emergency service, hospital, Electronic health records, Nursing services, Triage, Referral and consultation
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원문 및 링크아웃 정보
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등재저널 정보
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