전자간호기록에 사용된 표준간호진술문의 활용실태

Abstract

Purpose: This study was to describe and analyse standard nursing statements based on electronic nursing records according to nursing process. Method: Data were collected by analyzing electronic nursing records of 11,257 patients between October 15, 2004 and January 15, 2005 at one university hospital in Seoul. Result: The average age of nurses was 29.5 years and the average work experience of nurses was 4.7 years. 35.26% of patients was admitted at internal medicine units and 52.24% of internal medicine patients was diagnosed as cancer. 19.59% of patients was admitted at pediatrics and 25.42% of pediatric patients was diagnosed as congenital malformation. Nurses used 3,744(72.91%) of standard nursing assessment statements, 149(69.30%) of standard nursing diagnosis statements and 2,641(68.60%) of standard nursing action statements. 57.30% of standard nursing statements which used by nurses was nursing assessment statements, 2.28% was standard diagnosis statements and 40.42% was nursing action statements. ‘no respiratory difficulty’, ‘O2 inhalation’, ‘Pain’, ‘Risk for infection’, ‘vital sign was checked’ was frequently used statements at internal medicine units. ‘no wound oozing’, ‘sleeping now’, ‘Acute pain’, ‘Risk for infection’, ‘temperature was checked’, ‘support pain site was frequently used statements at general surgery units. Conclusion: The findings of this study provided the important basic data to develop nursing intervention special to clinical sections and showed the usability of ICNP as terminology of electronic nursing records system.