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이순영 ( Lee Soon-Young ) - 국군간호사관학교
정유미 ( Jung Yoo-Mi ) - 국군간호사관학교
안진옥 ( An Jin-Ok ) - 국군수도병원
차진희 ( Cha Jin-Hee ) - 국군수도병원
이현지 ( Lee Hyun-Ji ) - 국군수도병원
변다희 ( Byeon Da-Hee ) - 국군대구병원
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Abstract
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Purpose : This study is to investigate the overall use of standardized nursing statements in NDEMIS, the electronic nursing record system of Korean military hospitals and to identify frequently used statements among them by hospitals and treatment departments.
Methods : The authors analyzed the nursing records of randomly chosen 4 weeks from 12 military hospitals in 2015. Descriptive statistics were used to investigate the utilization rate of nursing problems, nursing interventions, and nursing activities in the standardized nursing statements.
Results : Analyzed were 245,252 nursing records of 9,532 patients who had been admitted to military hospitals. The nursing records contained 48.0% of the standardized nursing statements. Among them, the most frequently used statements were `acute pain` for nursing diagnosis, `Pain management` for nursing intervention, `notify medical team if pain worsens` and `assess pain` for nursing activity. The pattern of standardized nursing statements` use by hospitals and treatment departments reflected general characteristics of patients admitted to the military hospitals.
Conclusion : This study indicates that the priority in military nursing care is management of pain. Considering the percentage of standardized nursing statements, education for nursing staff should be regularly provided to promote use of them. Also NDEMIS should be improved according to the user`s needs so that the system can be fully utilized.
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KeyWords
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군병원, 간호기록, 표준간호진술문, 간호진단, 간호중재
Military hospital, Nursing record, Standardized nursing statement, Nursing diagnosis, Nursing intervention
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원문 및 링크아웃 정보
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등재저널 정보
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