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KMID : 1190620090050020094
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Journal of the Korean Wound Care Society
2009 Volume.5 No. 2 p.94 ~ p.97
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Analysis of Wound Care Concepts in Home Health Care Documentation
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Kim Ji-Hyun
Park Hyeoun-Ae
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Abstract
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Patient record is the most important tool in the evidence of home care services by nurse and for communication among multiple disciplinary domain experts. The purpose of research is to analysis for wound care concept in home health care documentation and to propose a method for efficient wound care recording. Nursing concepts from home care documentation were selected, and matched to Omaha system. Wound care concepts were defined and selected by categorizing "impaired skin integrity" and "skin". The most concept in wound care intervention concepts was "treatments and procedure" and the most concept in wound care problem concepts was "rash". Concepts from home care record had high abstraction and few detailed representing components. For improving quality and accuracy of nursing record, the standardized and structured nursing documentation is critical. And the electronic nursing record has the potential to support the reusability of data in that documentation. (J Korean Wound Management Soc 2009;5:94-97)
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KEYWORD
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Standard nursing terminology, Wound care documentation, Home care nursing
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Listed journal information
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