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조인숙 ( Cho In-Sook ) - 인하대학교 간호학과
최원자 ( Choi Won-Ja ) - 서울특별시보라매병원 간호부
최완희 ( Choi Wan-Hee ) - 서울대학교병원 간호부
김민경 ( Kim Min-Kyeong ) - 인하대학교 대학원
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Abstract
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Purpose: To provide clear estimates of the adoption and use of electronic nursing records (ENRs) with standard
terminology in Korea and identification of the scope and use as well as perceived or potential benefits of ENRs.
Methods: A survey was done of 733 hospitals at three levels: tertiary advanced hospitals, general hospitals, and
community hospitals. After performing a literature review a modified version of an existing survey tool was used
for 2 months in 2012. The collected information related to EHR functionality and coverage of nursing documentation
and nursing process, application of standard terminology, and perceived satisfaction and benefits
of ENRs.
Results: The response rate was 39.4% (289/733), and 202 hospitals (70.1%, 95% CI64.8~75.5%) of the
respondents had ENR systems (82.5% of tertiary hospitals, 66.7% of general hospitals, and 70.1% of community
hospitals). Out of these hospitals less than 10% had ENRs fully covering nursing documentation. The adoption
rate of standard terminology was 55%, and hospital satisfaction with ENRs was 70%. But personalized care was
identified as needing improvement in ENRs.
Conclusion: The ENR adoption rate was high but there are many
potential opportunities for improving ENR systems in terms of the data standardization and personalized care.
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KeyWords
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간호기록, 전자의무기록시스템, 간호정보, 표준 간호용어, 횡단적 연구
Nursing records, Medical records systems, Nursing informatics, Vocabulary, Cross-sectional survey
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원문 및 링크아웃 정보
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등재저널 정보
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