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KMID : 0377619930580090599
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Korean Jungang Medical Journal
1993 Volume.58 No. 9 p.599 ~ p.614
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A Study on Nursing Care Quality through Nursing Record Audit
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Abstract
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This study attempted to measure the quality of nursing care activities through patient´s records. The subjects consisted of 90 cases discharged from medical, surgical, obstetric & gynecology unit of a university hospital from June 1 to June 30, 1993. Nursing record audit was done for the 7 days of hospitalization and the results are as follows;
1. Scores by nursing care area were high in medical unit (43.2 %), surgical unit (39.4 %) on the nursing care area of diagnostic exams and treatments. In obstetric & gynecology unit nursing care planning obtained high score (40.1 %).
The low score showed in all three units on the psychosocial nursing care area.
2. Scores by nursing care items presented high in the medical unit (34.3 %), surgical unit (30.6 %) on the item of medication & nursing treatment and however obstetric & gynecology unit item of the assessment of patient current condition obtained high score (30.6%).
3. Scores by nursing care function of independent and dependent showed the ratio of 22.8 %: 77.2 % (IM unit), 24.2 %: 75.8 % (GS unit) and 30.9 %: 69.1 % (OBGY unit). Score of independent function was high in the psychosocial nursing care area of all three units and scores of dependent function was high in the area of diagnostic exam and treatments.
4. Differences between independent function and dependent function of all area of nursing care activities were statistically significant (P < .001).
5. Differences between type of unit and nursing care area revealed statistical significance (P <.001).
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KEYWORD
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