OBJECTIVES: The purpose of this study was to examine the applicability of the International Organization for Standardization (ISO) reference terminology model for nursing to describe the terminological value domain content regarding the entities and attributes of the detailed clinical models (DCMs) used for nursing assessments. METHODS: The first author mapped 52 DCM entities and 45 DCM attributes used for perinatal care nursing assessments to semantic domains and their qualifiers to the ISO model. The mapping results of the entity and attribute concepts were classified into four categories: mapped to a semantic domain qualifier, mapped to a semantic domain, mapped to a broader semantic domain concept, and not mapped. The DCM mapping results were classified into three categories: fully mapped, partially mapped, and not mapped. The second author verified the mapping. RESULTS: All of the entities and 53.3% of the attribute concepts of the DCMs were mapped to semantic domains or semantic domain qualifiers of the ISO model, 37.8% of the attributes were mapped to the broader semantic domain concept, and 8.9% of the attributes were not mapped. At the model level, 48.1% of the DCMs were fully mapped to semantic domains or semantic domain qualifiers of the ISO model, and 51.9% of the DCMs were partially mapped. CONCLUSIONS: The findings of this study demonstrate that the ISO reference terminology model for nursing is applicable in representing the DCM structure for perinatal care nursing assessment. However, more qualifiers of the Judgment semantic domain are required in order to clearly and fully represent all of the entities and attributes of the DCMs used for nursing assessment.
Concept Formation ; Judgment ; Medical Records Systems, Computerized ; Nursing Assessment ; Perinatal Care ; Semantics

OBJECTIVE: Archetypes as structured models of clinical content are considered to be the key broker between the reference models and terminology. This study developed and validated archetypes for nursing problems with breast cancer patients. METHODS: Archetypes were developed with the focuses and characterizing categories to describe the nursing problems identified from the perioperative nursing records of breast cancer patients, a literature review and experts' survey. The archetypes were validated by experts and applied to the clinical cases. RESULTS: Forty seven focuses and 22 characterizing categories of nursing problems were identified. Forty five archetypes, except for the symptoms of URI and vital signs, could be grouped into 16 different types. The symptoms of URI and vital signs were modeled by a combination of other archetypes. The experts' evaluation and application to clinical cases demonstrated the validity of the archetypes developed. CONCLUSION: Archetypes for nursing problems developed in this study can ensure interoperability and contribute to the exchange and sharing of the high quality structured data and information.
Breast ; Breast Neoplasms ; Dietary Sucrose ; Humans ; Nursing Diagnosis ; Perioperative Nursing ; Vital Signs

PURPOSE: The purpose of this study was to identify the degree of menopause symptoms and associated factors in patients with breast cancer who were receiving hormone therapy. METHODS: Data were collected with questionnaires from 150 patients with breast cancer who had been on hormone therapy at a hospital in Seoul. Data were analyzed with the t-test, ANOVA, and Pearson correlation coefficient to compare the degree of menopause symptoms by demographic, clinical and psychological factors. RESULTS: The mean menopause symptoms score was 13.39±7.97. Most participants reported having hot flushes and sweating (75.3%), physical and mental exhaustion (82.7%) and sexual problems (64.7%). Menopause symptoms and depression were correlated with each other (p < .01). Somato-vegetative symptoms were different significantly by age, menopausal status at time of operation, occupation and tumor. Psychological symptoms were different significantly by marital status, operation type and chemotherapy. Urogenital symptoms were different significantly by prior history of cancer, occupation, operation type and radiation therapy. CONCLUSION: These findings can be used to provide tailored nursing interventions by identifying high risk groups for menopausal symptom among breast cancer patients receiving hormone therapy.
Antineoplastic Agents, Hormonal ; Breast Neoplasms ; Breast ; Depression ; Drug Therapy ; Female ; Humans ; Marital Status ; Medication Adherence ; Menopause ; Nursing ; Occupations ; Psychology ; Seoul ; Sweat ; Sweating

This study was done to evaluate the effect reducing artificial dead space on intubated children. Data were collected from July 1st, 1998 to August 31st, 1999. The subjects were selected from a pediatric intensive care unit of 'S' hospital and intubated with 3.5 mm or 4.5 mm endotracheal tube after open heart surgery. They were composed of 34 patients : 17 patients were assigned to the experimental group and the rest of them were placed in the control group. The artificial airway volume was minimized in the experimental group, and the control group maintained the artificial airway volume. ETCO2, PaCO2, SPO2 were measured as indicators of pulmonary ventilation. The tools of this study were GEM-Premier and Space-Lab patient monitors. The data were analyzed using the SPSS/PC+ program. The Chi2 -test was used to find general characteristics. The t-test was used to test the homogenety of the pulmonary ventilation status and mechanical ventilation setting before intervention between the two groups. Also, the paired t-test was used to examine the hypothesis. The results can be summerized as : 1. CO2 can be expelled effectively from the body in case artificial dead space was decreased. 2. As the artificial dead space was reduced, the difference between ETCO2 and PaCO2 was decreased, in other words pulmonary ventilation was improved. 3. If the artificial dead space occupied above 15 percent of tidal volume, the effect of CO2 was retention revealed in the body. 4. If the artificial dead space occupied below 1.5 percent of tidal volume, there was no dead space effect. Based on the results, the following is suggested to be applied practically : 1. A kind of the ventilator circuit acting artificial dead space should be removed from the intubated children with mechanical ventilaion. 2. The endotracheal tube should not be cut because extra-body space of the endotracheal tube did not have an effect on the dead space of the intubated children. Since the researcher could not cover this aspect in the study, they recommend the following. 1. The study should be extended to the other pulmonary disease patients for the effect of improving pulmonary ventilation. 2. Also, further studying with a more narrow interval in the extra-body space of the artificial airway will be able to explain the point of artificial dead space with proper ventilation.
Child* ; Humans ; Intensive Care Units ; Lung Diseases ; Pulmonary Ventilation* ; Respiration, Artificial* ; Thoracic Surgery ; Tidal Volume ; Ventilation ; Ventilators, Mechanical

Around the world electronic health records data are being shared and exchanged between two different systems for direct patient care, as well as for research, reimbursement, quality assurance, epidemiology, public health, and policy development. It is important to communicate the semantic meaning of the clinical data when exchanging electronic health records data. In order to achieve semantic interoperability of clinical data, it is important not only to specify clinical entries and documents and the structure of data in electronic health records, but also to use clinical terminology to describe clinical data. There are three types of clinical terminology: interface terminology to support a user-friendly structured data entry; reference terminology to store, retrieve, and analyze clinical data; and classification to aggregate clinical data for secondary use. In order to use electronic health records data in an efficient way, healthcare providers first need to record clinical content using a systematic and controlled interface terminology, then clinical content needs to be stored with reference terminology in a clinical data repository or data warehouse, and finally, the clinical content can be converted into a classification for reimbursement and statistical reporting. For electronic health records data collected at the point of care to be used for secondary purposes, it is necessary to map reference terminology with interface terminology and classification. It is necessary to adopt clinical terminology in electronic health records systems to ensure a high level of semantic interoperability.
Dietary Sucrose ; Electronic Health Records ; Electronics ; Electrons ; Health Personnel ; Humans ; Patient Care ; Policy Making ; Public Health ; Semantics

OBJECTIVES: The purpose of this study was to test the feasibility of an electronic nursing record system for perinatal care that is based on detailed clinical models and clinical practice guidelines in perinatal care. METHODS: This study was carried out in five phases: 1) generating nursing statements using detailed clinical models; 2) identifying the relevant evidence; 3) linking nursing statements with the evidence; 4) developing a prototype electronic nursing record system based on detailed clinical models and clinical practice guidelines; and 5) evaluating the prototype system. RESULTS: We first generated 799 nursing statements describing nursing assessments, diagnoses, interventions, and outcomes using entities, attributes, and value sets of detailed clinical models for perinatal care which we developed in a previous study. We then extracted 506 recommendations from nine clinical practice guidelines and created sets of nursing statements to be used for nursing documentation by grouping nursing statements according to these recommendations. Finally, we developed and evaluated a prototype electronic nursing record system that can provide nurses with recommendations for nursing practice and sets of nursing statements based on the recommendations for guiding nursing documentation. CONCLUSIONS: The prototype system was found to be sufficiently complete, relevant, useful, and applicable in terms of content, and easy to use and useful in terms of system user interface. This study has revealed the feasibility of developing such an ENR system.
Concept Formation ; Electronics ; Electrons ; Evidence-Based Practice ; Medical Records Systems, Computerized ; Nursing Assessment ; Nursing Records ; Perinatal Care ; Semantics

OBJECTIVES: The purpose of this study was to test the feasibility of an electronic nursing record system for perinatal care that is based on detailed clinical models and clinical practice guidelines in perinatal care. METHODS: This study was carried out in five phases: 1) generating nursing statements using detailed clinical models; 2) identifying the relevant evidence; 3) linking nursing statements with the evidence; 4) developing a prototype electronic nursing record system based on detailed clinical models and clinical practice guidelines; and 5) evaluating the prototype system. RESULTS: We first generated 799 nursing statements describing nursing assessments, diagnoses, interventions, and outcomes using entities, attributes, and value sets of detailed clinical models for perinatal care which we developed in a previous study. We then extracted 506 recommendations from nine clinical practice guidelines and created sets of nursing statements to be used for nursing documentation by grouping nursing statements according to these recommendations. Finally, we developed and evaluated a prototype electronic nursing record system that can provide nurses with recommendations for nursing practice and sets of nursing statements based on the recommendations for guiding nursing documentation. CONCLUSIONS: The prototype system was found to be sufficiently complete, relevant, useful, and applicable in terms of content, and easy to use and useful in terms of system user interface. This study has revealed the feasibility of developing such an ENR system.
Concept Formation ; Electronics ; Electrons ; Evidence-Based Practice ; Medical Records Systems, Computerized ; Nursing Assessment ; Nursing Records ; Perinatal Care ; Semantics

OBJECTIVES: This study analyzed smartphone obesity-management applications developed in Korea and the quality of the information that they provide. METHODS: Obesity-management smartphone applications were searched using the keywords 'obesity + management,' 'weight + management,' 'weight + loss,' 'weight + exercise,' 'weight + diet,' 'weight + calories,' and 'diet,' with a search application programming interface (provided by Apple) between September 23 and September 27, 2013. These applications were then classified according to their main purpose, type of interventions used, price, type of developer, and user ratings. The information quality of the applications was analyzed using the Silberg scale. RESULTS: In total, 148 smartphone applications for obesity management were found. The main purpose of most of these applications (70.95%) was to provide information regarding weight control. The most frequently used intervention (34.62%) was to provide information on exercise management. More than half of the applications (58.78%) were free of charge. The mean of users' rating of these applications was 3.68 out of 5. The quality of information provided by these applications was evaluated as 4.55 out of 9: specifically, 1.79 out of 3 for authorship, 0.22 out of 2 for attribution, 1.29 out of 2 for disclosure, and 1.25 out of 2 for currency. Only three of the applications (2.88%) had a score on the Silberg scale greater than or equal to 7 points. CONCLUSIONS: The findings of this study suggest that the quality of information provided by smartphone applications in the healthcare domain urgently need to be evaluated to prevent users being misinformed by these applications.
Authorship ; Delivery of Health Care ; Disclosure ; Korea ; Mobile Health Units ; Obesity ; Telemedicine ; Weight Loss

OBJECTIVES: The purpose of this paper is to describe the components of a next-generation electronic nursing records system ensuring full semantic interoperability and integrating evidence into the nursing records system. METHODS: A next-generation electronic nursing records system based on detailed clinical models and clinical practice guidelines was developed at Seoul National University Bundang Hospital in 2013. This system has two components, a terminology server and a nursing documentation system. RESULTS: The terminology server manages nursing narratives generated from entity-attribute-value triplets of detailed clinical models using a natural language generation system. The nursing documentation system provides nurses with a set of nursing narratives arranged around the recommendations extracted from clinical practice guidelines. CONCLUSIONS: An electronic nursing records system based on detailed clinical models and clinical practice guidelines was successfully implemented in a hospital in Korea. The next-generation electronic nursing records system can support nursing practice and nursing documentation, which in turn will improve data quality.
Data Accuracy ; Evidence-Based Practice ; Humans ; Korea ; Medical Records Systems, Computerized ; Nursing Records* ; Nursing* ; Semantics ; Seoul ; Triplets

PURPOSE: The transtheoretical model (TTM) was used to provide tailored nursing for lifestyle management such as diet, physical activity, and smoking cessation. The present study aims to assess the provision of intervention delivery methods, intervention elements, and stage-matched interventions, in order to identify ways in which information technology is used in the TTM-based research. METHODS: The relevant literature was selected by two researchers using inclusion criteria after searching for "TTM (transtheoretical or stage of change)" and "nursing" from the databases PubMed and CINAHL. The selected studies were categorized in terms of study characteristics, intervention delivery method, intervention element, and use and level of stage-matched intervention. RESULTS: A total of 35 studies were selected including eight studies that used information communication technology (ICT). Nine different intervention delivery methods were used, of which "face-to-face" was the most common at 24 times. Of the 35 studies, 26 provided stage-matched interventions. Seven different intervention elements were used, of which "counseling" was the most common at 27 times. Of all the intervention elements, tailored feedback used ICT the most at seven instances out of nine, and there was a significant difference in the rate of ICT usage among intervention elements. CONCLUSIONS: ICT is not yet actively used in the TTM-based nursing interventions. Stage-matched interventions and TTM concepts were shown to be in partial use also in the TTM-based interventions. Therefore, it is necessary to develop a variety of ways to use ICT in tailored nursing interventions and to use TTM frameworks and concepts.
Communication ; Diet ; *Health Behavior ; Health Promotion/*methods ; Humans ; *Life Style ; *Models, Theoretical ; Motor Activity ; Nursing Research/*methods ; Smoking