전자간호기록 적용 전ㆍ후 환자의 간호기록 비교: 복식자궁절제술 환자를 중심으로 = A Comparison of the Nursing Records of Hysterectomy Patients: Pre and Post Implementation of an ICNP Based Electronic Nursing Record System

다국어 초록 (Multilingual Abstract)

Objective: This study compared the abilities of electronic nursing records, which are based on standard nursing terminology, and paper-based nursing records to support the nursing process. Methods: The nursing records of 38 pairs of inpatients admitted to a gynecology nursing unit were selected. The data from the paper records were obtained manually by a chart review as single statement units. The electronic records were extracted from a computerized system. The statements were categorized using the NANDA diagnosis and the modified Clinical Care Classification. Based on a semantic analysis of the components of the nursing process, the completeness of the nursing records was classified into complete and incomplete patterns according to the presence and relevancy of the assessment, the diagnosis, the intervention and the outcome. Results: The numbers of nursing diagnoses used and the unique nursing diagnoses were both higher in the electronic records than those in the paper records. The number of statements of nursing assessments/outcomes, and nursing interventions was 1.4-fold higher in the electronic records than that in the paper records respectively. The proportion of complete patterns of the nursing process was 3.4% in the paper records and 25.7% in the electronic records. Conclusion: These results suggest that electronic records are better than paper records to support the nursing process in terms of the quantitative and qualitative aspects of nursing documentation.

참고문헌 (Reference)

1 Lee KH, "Women's Health Nursing I, II" Hyunmoon Press 1342-1358, 2003

2 Nursing Text Society for the Research of Women's Health, "Women's Health Nursing I, II" Soomoonsa 1108-1120, 2006

3 ICN, "The 7-axis model of version 1(chap 4)"

4 Hardiker NR, "Standards for nursing terminology" 7 (7): 523-528, 2000

5 Bakken S, "Standardized terminologies for nursing concepts: collaborative activities in the United States" International Medical Informatics Association 21-32, 2000

6 American Nursing Association, "Nursing informatics: Scope and standards of practice" Silver Spring 1-15, 2008

7 Park HA, "Nursing diagnosis, intervention, outcome classification" Seoul National University Press 5-24, 2000

8 Carpenito-Moyet LJ, "Nursing care plans and documentation. 4th ed" Williams & Wilkins 3-26, 2004

9 North America Nursing Diagnosis Association, "Nursing Diagnosis: Definition and Classifications 2001-2002" 13-207, 2001

10 Carpenito-Moyet LJ, "Nursing Diagnosis. Application to clinical practice. 10th ed" Lippincott Williams & Wilkins 80-938, 2004

11 Seoul National University Hospital, "Nursing Diagnosis and Planning" Seoul National University Press 335-350, 1994

12 Nahm R, "Measurement of the effects of an integrated, point-of-care computer system on quality of nursing documentation and patient satisfaction" 18 (18): 220-229, 2000

13 Gabrieli ER, "Longitudinal electronic patient records: a challenge of our time" 15 (15): S48-S52, 1997

14 조인숙, "ICNP 활용 전자간호기록 시스템을 위한 수작업 간호기록내용 분석: 모성간호기록을 중심으로" 대한의료정보학회 8 (8): 1-13, 2002

15 Hardiker NR, "Formal nursing terminology systems: a means to an end" 35 (35): 298-305, 2002

16 Cho I, "Evaluation of the expressiveness of an ICNP-based nursing data dictionary in a computerized nursing record system" 13 (13): 456-464, 2006

17 Larrabee JH, "Evaluation of documentation before and after implementation of a nursing information system in an acute care hospital" 19 (19): 56-68, 2001

18 Smith K, "Evaluating the impact of computerized clinical documentation" 23 (23): 132-138, 2005

19 Park HA, "Development of nursing information system component and interface model for integrated medical information system" Ministry of Health and Welfare 31-66, 2003

20 Park SA, "Development of computerized program for nursing diagnosis and Intervention linked to medical diagnosis" 8 (8): 239-248, 2002

21 Cho I, "Development and evaluation of a terminology-based electronic nursing record system" 36 (36): 304-312, 2003

22 Song MS, "Comparison of nusing activities reflected in nursing notes and in-depth interviews of nurses in an acute hospital" 33 (33): 802-811, 2003

23 Seoul National University Hospital, "Clinical nursing process application as based on ENR" Hyunmoon Press 33-884, 2007

24 Saba V, "Clinical Care Classification (CCC) System Manual" Springer Publishing Company 103-240, 2007

25 Marin HF, "Building standard-based nursing information systems. Pan American Health Organization" World Health Organization 12-15, 2001

26 Kim YJ, "Analysis of nursing records of cardiac-surgery patients based on the nursing process and focusing on nursing outcomes" 74 (74): 952-959, 2003

27 Myung HJ, "Analysis of nursing notes to develop an ICNP-based electronic nursing records system-Focused on general surgery patients' nursing records" Seoul National University 2003

28 Lee CH, "A study on the effects of EMR on nursing documentation" 6 (6): 87-97, 2000

29 Chi SA, "A basic study on improvement and computerization of nursing record" 29 (29): 21-33, 1999