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전산간호기록과 서면간호기록의 효율성에 관한 비교연구: 급성 뇌졸중 환자의 간호기록 중심으로

 A Comparison of Efficiency between Computerized Nursing Records and the Paper-based Nursing Records: focus on patients with a stroke

기본간호학회지 2006년 13권 1호 p.24 ~ 32
KMID : 0388320060130010024
성영희 ( Sung Young-Hee ) - 삼성서울병원 간호부

조명숙 ( Cho Myoung-Sook ) - 삼성서울병원
최복연 ( Choi Bok-Yeon ) - 삼성서울병원
장미라 ( Jang Mi-Ra ) - 삼성서울병원 간호부

Abstract

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 the 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.
KeyWords
간호기록
Nursing records
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학술진흥재단(KCI) KoreaMed