Analysis of Medical Records and Development of Chest Pain Care Record in the Emergency Department.
- Author:
Gui Yun CHOI
1
;
Young Sook MOON
;
Eun Seog HONG
Author Information
1. Department of Nursing, Ulsan College, Korea. gychoi@mail.uc.ac.kr
- Publication Type:Original Article
- Keywords:
Emergencies;
Chest pain;
Nursing records
- MeSH:
Chest Pain*;
Emergencies*;
Emergency Service, Hospital*;
Humans;
Medical Records*;
Nursing;
Nursing Records;
Retrospective Studies;
Statistics as Topic;
Thorax*
- From:Journal of Korean Academy of Adult Nursing
2006;18(4):533-542
- CountryRepublic of Korea
- Language:Korean
-
Abstract:
PURPOSE: The purposes of this study were to investigate medical records and to develop care records for management of patients with chest pain in the emergency department. METHOD: Retrospective review of the 42 medical chart of patients presented to the emergency department with chest pain were used. The collected data were analyzed with a frequency of items in the medical records. RESULTS: In a frequency analysis of recorded items for doctors' chest pain assessment during history taking, the history/risk factors was the highest rank. The following ranks were 'commenced with when/ timing, extra symptoms, place, nature, stay/ radiate, alleviate/aggravate, intensity' in sequence. In a frequency of recorded items in nurse's progress notes according to nursing actions, the 'checking/monitoring' was the highest rank. The following ranks were 'performing, administering/injecting, referring/ arranging, testing, preparing/catheterizing, teaching/informing' in sequence. Chest pain care records for the emergency department was designed, based upon data analysis and literature review. CONCLUSION: The designed records can be a rapid and effective approach tool for assessment and recording of patients with chest pain. Further research is necessary for evaluating the designed chest pain care records.
