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KMID : 1004620090150030107
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Clinical Nursing Research
2009 Volume.15 No. 3 p.107 ~ p.116
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Evaluation on the Record Completeness of the Nursing Process in Electronic Nursing Record for Patients Undertaken Gastrectomy
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Park Ihn-Sook
Yoo Cheong-Sook
Lee Soon-Hyung
Woo Kyung-Shun
Joo Young-Hee
Choi Wan-Hee
Kang Hyun-Sook
Jung Mi-Ra
Kim Hee-Jin
Park Mi-Ok
Lee Su-Hee
Ahn Seon-Yeong
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Abstract
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Purpose: This study was conducted to evaluate the record completeness of the nursing process in the Electronic Nursing Record(ENR) in a university hospital.
Methods: We compared nursing statements documented in 2004 with those from the year 2007, given the fact that the ENR system had been utilized since 2004. The ENRs of 35 gastrectomy patients in each year were selected for evaluation. The selected data were 11,822 nursing statements in 2004 and 27,870 in 2007.
Results: The number of nursing records which documented the whole nursing process completely was 4,010
(48.3%) in 2007, whereas 513 (5.9%) in 2004 (p<.001). The number of incomplete records in 2004 was 8,142 (94.1%), while 4,300 (51.7%) in 2007 (p<.001). The number of nursing diagnoses was 846 in 2004 and 4,313 in 2007, which increased in number more than 5 times. The most frequently used diagnoses were ‘pain’, ‘risk for infection’ and ‘risk for ileus’ in both years.
Conclusion: There was a significant increase in the record completeness on nursing process in 2007 compared to the records in 2004. The reasons for this increase are attributed to nurse training for encouraging to complete recording and nursing record auditing.
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KEYWORD
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Electronic nursing records, Nursing process
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