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류선희 ( Rye Sun-Hee ) - 경북대학교 교육대학원 간호교육학과
홍해숙 ( Hong Hae-Sook ) - 경북대학교 간호대학
박상연 ( Park Sang-Youn ) - 경북대학교 간호대학
이은주 ( Lee Eun-Joo ) - 경북대학교 의과대학 간호학과
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Abstract
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The purpose of this study was to establish the basic-data set for the electronic nursing records system by analysis of nursing phenomenas and nursing actions described in nursing records of orthopedic patients using the ICNP. Nursing notes for 1.421 days of 97 orthopedics patients who were discharged from a tertiary teaching hospital in Daegu were used. Narrative data from the nursing notes were collected. decomposed. and cross mapped with the concepts of the ICNP beta version. In total 11.442 statements were found in the process of decomposing the narrative data into single statement. These statements consist of 3.970(34.70%) nursing phenomena statements. 6.996(61.14%) nursing action statements, and 476(4.16%) other statements. Finally 312 unique statements were collected by integrating same or similar statements. These statements consist of 120 (38.46%) nursing phenomena statements. 154 (49.36%) nursing action statements. and 38 (12.18%) other statements. When this result was cross mapped with ICNP beta version. 77.0% of nursing statements were completely expressed. 17.0% of them were partially expressed. and 0.3% of them were not able to expressed at all. The findings of this study showed the usability of ICNP as terminology of electronic nursing records system. And the result of this study can be utilized for an ICNP-based electronic nursing records system and can help clinical nurses to spend more time on direct nursing.
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KeyWords
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전자간호기록
ICNP, Nursing Phenomena, Nursing action, ENR
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원문 및 링크아웃 정보
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등재저널 정보
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