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박인숙 ( Park Ihn-Sook ) - 서울대학교병원
유정숙 ( Yoo Cheong-Sook ) - 서울대학교병원
이순형 ( Lee Soon-Hyung ) - 서울대학교병원
우경선 ( Woo Kyung-Shun ) - 서울대학교병원
주영희 ( Joo Young-Hee ) - 서울대학교병원
최완희 ( Choi Wan-Hee ) - 서울대학교병원 간호부
강현숙 ( Kang Hyun-Sook ) - 서울대학교병원
정미라 ( Jung Mi-Ra ) - 서울대학교병원
김희진 ( Kim Hee-Jin ) - 서울대학교병원
박미옥 ( Park Mi-Ok ) - 서울대학교병원
이수희 ( Lee Su-Hee ) - 서울대학교병원
안선영 ( Ahn Seon-Yeong ) - 서울대학교병원
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Abstract
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Purpose: This study was conducted to evaluate the record completeness of the nursing process in the Electronic Nursing Record(ENR) in a university hospital.
Methods: We compared nursing statements documented in 2004 with those from the year 2007, given the fact that the ENR system had been utilized since 2004. The ENRs of 35 gastrectomy patients in each year were selected for evaluation. The selected data were 11,822 nursing statements in 2004 and 27,870 in 2007.
Results: The number of nursing records which documented the whole nursing process completely was 4,010
(48.3%) in 2007, whereas 513 (5.9%) in 2004 (p<.001). The number of incomplete records in 2004 was 8,142 (94.1%), while 4,300 (51.7%) in 2007 (p<.001). The number of nursing diagnoses was 846 in 2004 and 4,313 in 2007, which increased in number more than 5 times. The most frequently used diagnoses were ‘pain’, ‘risk for infection’ and ‘risk for ileus’ in both years.
Conclusion: There was a significant increase in the record completeness on nursing process in 2007 compared to the records in 2004. The reasons for this increase are attributed to nurse training for encouraging to complete recording and nursing record auditing.
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KeyWords
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전자간호기록, 간호과정
Electronic nursing records, Nursing process
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원문 및 링크아웃 정보
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등재저널 정보
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