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KMID : 0378019780210040098
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New Medical Journal
1978 Volume.21 No. 4 p.98 ~ p.106
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A Study on the Nursing Record of the Clinical Staff Nurses
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Abstract
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A study on the Nursing Record was carried out to identify the staff nurse´s perceptions towards the Nursing Record and to find out it´s utilization for the various health personnels in hospital and the nursing recording behaviors of the staff nurses. A questionnaire developed by researcher was administrate to 203 staff nurse at 4 University Hospitals in Seoul to gather the data on Dec., 1976 to Jan., 1977. Data obtained from this study were analized into percentage and Chi-square test in order to determine their significances and the results are as follows; 1. In the perception towards the Nursing Record, 83.7% of all respondents thought that was a recording of the nursing activities carried out according to the Dr´s order and the independent decision of the nurse (83.7%). There was no significant relationship between this perception and the kind of education or clinical experience of the staff nurses (P>0.005) 2. According to the analysis of the grade of the influences of clinical utilization of Nursing Record in the several fields of treatment. a. For the treatment, Nursing Record was useful "very much" (71.4%), or "moderately" (26.1%). There was significant difference in this point between National University Hospital and Private University Hospital (P<0.05). b. For the communication among the hospital personnels, the nursing education, and the change of Doctor´s order, the Nursing Record was used "moderately" (50.7%, 48.3%, 53.2%) or "very much" (40.9%, 47.3%, 36.0%) respectively. There was no significant difference in the different hospital (P>O. 05). c. The cases of having changed Doctor´s order after their reading the Nursing Record was 74.9% and the most categories of the changed Doctor´s order were the items of medication and treatment (40.1%). 3. In the behaviors of Nursing Record, 69.5% of all respondents had experience of having missed Nursing Record and their causes were "oral reported" (32.6%), "forget to record" (24.2%), "no need to record" (21.9%), etc. There was no significance in the causes of missed Nursing Record by their kinds of education or clinical experience. 58.1% of all respondents had experiences of having mistaken Nursing Record and 26.6% of them had the obscure Nursing Records. 4. 79.9% of all respondents were satisfied with using the present Nursing Record sheet, but 20.1% were not satisfied. The main causes of the dissatisfactions were "taking repetition" (58.5%), "taking obscurity” (21.5%) and "taking times” (20.0%). 5. 66% of all respondents were not influenced to write the Nursing Record from their emotional and physical conditions. 6. In the professional point of view, most of the respondents (69.5%) had read some professional textbooks or articles and more than half of them (53.7%) expect to have a continuing education about the Nursing Record in their hospitals.
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KEYWORD
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