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송미라 ( Song Mi-Ra ) - Samsung Medical Center Department of Nursing
심소연 ( Shim So-Yun ) - Samsung Medical Center Department of Nursing
김대성 ( Kim Dae-Sung ) - Samsung Medical Center
이경순 ( Lee Kyong-Soon ) - Korea University Anam Hospital Department of Nursing
이유나 ( Lee Yu-Na ) - Korea University Guro Hospital Department of Nursing
원미숙 ( Won Mi-Suk ) - Korea University Ansan Hospital Department of Nursing
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Abstract
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목적: 본 연구는 임상실무에 표준간호용어를 적용 가능한 범위와 방법을 모색하는 기초자료로 활용하고자 한다.
방법: 4개 상급종합병원에서 입원치료를 받은 141,420명의 전자의무기록을 후향적으로 분석하였다. 수집된 간호진단 및 문제를 표준화하고, 표준화된 간호진단 및 문제를 NANDA-I와 교차분석하고 전문가 그룹의 검증을 받았다.
결과: 96개의 용어 중 65개(67.7%)가 NANDA-I와 일치하는 것으로 나타났으며 10개 영역에 포함되었다. 교차분석에서 제외된 86개의 용어 중 63개(73.3%)는 수술, 시술과 관련된 용어가 많았다.
결론: 다기관의 간호진단 및 문제를 표준화하고 표준간호용어와 교차분석해 본 연구로 의미가 있다. 임상실무에서 표준간호용어를 활용하기 위해서는 여러 표준간호용어체계를 활용할 필요가 있다.
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Purpose: To explore the scope and method of applying standardized nursing terminologies to nursing diagnosis and problems used in nursing practice.
Methods: A descriptive study was done with a retrospective analysis of the nursing records of 141,420 patients that were hospitalized in 4 tertiary hospitals. The nursing diagnosis and problems collected from the records were standardized, and the standardized nursing diagnosis and problems cross mapped with NANDA-I, confirmed in a nursing focus group.
Results: 65 (67.7%) of the 96 standardized nursing diagnosis and problems were equal with NANDA-I and included in the 10 domains of NANDA-I. Among 86 nursing diagnosis and problems excluded from the cross mapping with NANDA-I, the 63 terms (73.3%) related to surgery/procedure were the most common.
Conclusion: It is meaningful that multi-tertiary hospital nursing diagnosis and problems were standardized and cross mapping with standard nursing terminologies was performed. As for the method of applying standardized nursing terminologies in nursing practice, it is appropriate to use several standardized nursing terminologies complementarily.
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KeyWords
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간호진단, 간호기록, 표준간호용어
Nursing Diagnosis, Nursing Records, Standardized Nursing Terminology
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원문 및 링크아웃 정보
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등재저널 정보
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