The purpose of this research was to develop the clinical nursing process model through linked nursing diagnoses, related factors, defining characteristics, nursing interventions, nursing activities and nursing outcomes and was to make graphic user interface using the clinical nursing process model. The linked clinical record sets in the developed database system were arranged in reverse order statistically in order to construct the clinical nursing process model from the patients' database tables concerning nursing diagnoses, related factors, defining characteristics, nursing interventions, nursing activities and nursing outcomes. The arranged clinical nursing record sets were suggested as the nursing process model in a general surgery clinical unit. The nursing process model of a general surgery clinical unit could be used for its accessibility as an indicator for other medical departments. The most available clinical nursing process data were presented on only one graphic user interface window to be able to select the nursing process easily for nurses in a general surgery clinical unit. Graphic user interface programming was designed to show all related factors, defining character stics, nursing interventions, nursing activities and nursing outcomes based on a nursing diagnosis which have unique properties. Using the clinical nursing process model in this database system, it was also possible to construct the electronic nursing record system.
Nursing Diagnosis ; Nursing Process* ; Nursing Records ; Nursing*

PURPOSE: The purpose of this study was to examine the effects on knowledge and performance in clinical nurses who participated in education on nursing recording focusing on the legal aspects. METHOD: The participants were working in medical departments in one hospital. There were 32 nurses in the experimental group and 25 in the control group. Pre-test was conducted on the two groups before education, and, in order to examine the effects of education, a post-test was conducted after three weeks. For the experimental group, the education on nursing recording focusing on legal aspects was provided as a lecture-led one-to-one training. RESULTS: Significant differences were found between the experimental and control groups in knowledge (F=15.728, p<.001), and performance (F=42.454, p<.001). CONCLUSIONS: The results of this study indicate that education on nurse recording enhances the knowledge and performance of the nurses. Thus education on nurse recording focusing on legal aspects should be required in the area of nursing science.
Jurisprudence ; Nursing Records

This paper proposes a system for nursing diagnosis and intervention management that is using nursing outcome indicators to guide the nursing intervention. In Korea, it has been studied on computerization of nursing process, but most of the studies are on the management of nursing records and not on the databases of nursing intervention. So far, the actual nursing processes have been performed by individual nurses' judgement without any supporting programs. Therefore, we provide the system with standardized database for nursing diagnosis and interventions so that nurses can make more accurate diagnoses and perform more adequate interventions. For that purpose, we have developed an algorithm that links nursing outcome indicators to nursing diagnoses and interventions. As a result, we expect the system can be used in many hospitals efficiently in the future after pilot operations.
Diagnosis ; Korea ; Nursing Diagnosis* ; Nursing Process ; Nursing Records ; Nursing*

PURPOSE: The purpose of this study was to identify the association between safety care activity and documentation of nursing records among nurses working in hospitals and to provide basic data for developing hospital policy for the documentation of nursing records.METHOD: By using a self-reported questionnaire, data were collected from 212 nurses working in six general hospitals in Jeju province from November 2015. Data were analyzed using descriptive statistics, t-test, ANOVA, Pearson correlation coefficients, and stepwise multiple regression with the SAS WIN 9.2 program.RESULTS: Safety care activity was positively correlated with the documentation of nursing records (r=.83, p < .001). The documentation of nursing records was significantly predicted by safety care activity, working department, and nursing delivery system, and 70.9% of the variance in the documentation of nursing records was explained (F=172.31, p < .001).CONCLUSION: In this study, safety care activity was the most influencing factor for the documentation of nursing records. Improving work circumstances and building a system are required for nurses' safety care activity to lead to good documentation of nursing records.
Hospitals, General ; Methods ; Nursing Records ; Nursing

PURPOSE: The purpose of this study was to assess hospital nurses' knowledge, importance and performance in keeping nursing records.METHODS: The research design was a descriptive study. The sample for this study was 186 nurses with at least one year of work experience at a hospital with more than 800 beds in Seoul. Knowledge was self-reported using the Nurse Charting Knowledge Scale. Importance and performance were rated on a 4-point scale of 26 items. Data were analyzed by SPSS 21.0 program and IPA.RESULTS: This study showed significant results that knowledge, importance and performance for keeping record are related to each other. The importance and performance of nurse's records were relatively higher than the mean. In the IPA Matrix, there were 2 items requiring improvement, 13 items requiring maintenance, and 11 items with low priority.CONCLUSION: Therefore, awareness of the importance of record keeping and continuous education on nursing record knowledge should be provided so that nurses can improve their record keeping skills.
Education ; Nursing Records ; Nursing ; Research Design ; Seoul

PURPOSE: This study was conducted to compare the levels of pain intensity and pain relief between cancer patients and nursing records, and to compare the barriers to pain control between cancer patients and their nurses. METHODS: Data were collected from 90 cancer patients who were admitted to three oncology wards and 90 oncology nurses in the same three wards at C University Hospital in G City from July to September, 2012. RESULTS: The most severe pain intensity reported by cancer patients was 6.59 points on the first day of analgesic treatment, while that of their nursing records was 3.98 points on the first day. There were significant changes in pain intensity over time between two groups (F=142.07, p<.001). The highest level of pain relief reported by patients was 2.87 points on the third day, while that of nursing records was 1.67 points on the first day. The score for the social system area of barriers to pain control among the nurses was higher than that of cancer patients (t=-3.69, p=.021). CONCLUSION: Nurses need to frequently check and to be sensitive to cancer pain. Furthermore, the administrative procedures of narcotic analgesics need to be simplified.
Comprehension ; Humans ; Narcotics ; Nursing Records

PURPOSE: This study was done to develop a realistic clinical case and investigate nurses' decision-making about nurses' ethical dilemmas with physicians in the fields of nursing practice. METHODS: Case development and a hypothetical case study were used. Participants were 52 nurses. Data were collected in 2012 and 2013 using an open-ended questionnaire and interviews and analyzed using content analysis and descriptive statistics. RESULTS: Various dilemma situations between nurses and physicians, such as violence, deathbed, medication-prescription, and physicians' incapacity-unfairness, were suggested. A clinical dilemma case about medication-prescription was developed based on nurses' experiences. Nurses' responses to the developed case situation and responses were classified into five types. Various reasons were given for making the decisions and about 56% of the nurses decided to notify their supervisor without deleting nursing records. CONCLUSION: In this study, a realistic clinical dilemma case was developed, and nurses' ethical decision making was identified. These findings can be used in developing effective strategies for nurses to solve ethical dilemmas and to improve ethical decision-making abilities.
Decision Making* ; Ethics, Nursing ; Nursing ; Nursing Records ; Surveys and Questionnaires ; Violence

OBJECTIVES: The objective of this study is to compare nursing records before and after the implementation of an electronic nursing records system. METHODS: Twenty patients' paper-based nursing records and 20 patients' electronic nursing records were analyzed according to the nursing process and compared in terms of quantity and quality. RESULTS: In terms of quantity, the average number of statements documented per patient per day has increased by 2.5 times, from 10.3 to 25.6 statements. The average number of redundancies of a unique statement also has increased by 67%, from 5.0 to 8.8. As for the content of nursing records, paper-based nursing records have more patient problem statements describing signs and symptoms, nursing observations, and patient status. Electronic nursing records have more nursing activity statements. In terms of quality, there were more nursing records following patterns of nursing process in electronic nursing records than paper-based nursing records. The electronic nursing records have a more detailed documentation compared to the paper-based nursing records. CONCLUSION: After the implementation of electronic nursing record system, quantity of nursing records and the pattern of nursing records following the nursing process have been increased and granularity of nursing records has been improved.
Humans ; Nursing ; Nursing Process ; Nursing Records* ; Thoracic Surgery*

PURPOSE: this study is to explore how useful ICNP nursing phenomena and actions classification is to describe the nursing problem and nursing action statements of nursing records. METHOD: The number of nursing phenomena statements found in this research were 323. Out of these 323, 222 statements can be fully classified, 62 statements can be partially classified, and 39 statements can not be classified at all by terms from the ICNP phenomena classification axis. RESULT: The number of nursing practice statements were 318, 252 of which can be fully classified, 63 statements can be partially classified, 3 statements cannot be classified at all by terms from the ICNP nursing action classification axis. CONCLUSIONS: In order to describe all the statements found in nursing records, not only new terms but also new axis need to be added to the ICNP.
Axis, Cervical Vertebra ; Classification* ; Nursing Care ; Nursing Records* ; Nursing*

The Objectives of this study are to evaluate the user satisfaction and actual data input time through an enterprise ICNP-based electronic nursing record system using the controlled vocabulary in a secondary care hospital (BSNUH). Study design is a formative evaluation using the QUIS (Questionnaire user interaction satisfaction) self-reported in a secondary care hospital operating EMR(electronic medical record) system in Korea. Participants were two hundred fifty nurses in BSNUH. All of them were registered nurses participated in day-to-day nursing care during study periods. Participants were asked to fill in the SNCEQ(The Staggers Nursing Computer Experience Questionnaire) and QUIS(Questionnaire for User Interaction Satisfaction). Also requested were the data input time(sec) required for entry of approximately 20 times of nursing documentation tasks and the number of standardized precoordinated phrases used for documenting routine nursing records. The mean score of user satisfaction was 4.56 (SD 1.25) and the mean time of data input and the average number of precoordinated phrases used in nurses notes was 2.25min and 3.7 respectively.
Korea ; Nursing Care ; Nursing Records* ; Nursing* ; Secondary Care ; Vocabulary, Controlled