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Assessing How Well Electronic Nursing Records Reflect Changes in the Nursing Profession's Scope of Practice in Korea

Authors
 Seungshin Lee  ;  Soyoung Yu  ;  Hyunbong Park  ;  Tae Gon Kim 
Citation
 CIN-COMPUTERS INFORMATICS NURSING, Vol.38(6) : 312-319, 2020-06 
Journal Title
CIN-COMPUTERS INFORMATICS NURSING
ISSN
 1538-2931 
Issue Date
2020-06
MeSH
Activities of Daily Living ; Adult ; Electronic Health Records* ; Female ; Hospitals ; Humans ; Male ; Nurse's Role* ; Nursing Care* ; Republic of Korea ; Scope of Practice*
Keywords
Electronic health records ; Nursing practice ; Nursing record
Abstract
Electronic health records, a source of key administrative data for patient care, have been used in Korea for the past 13 years. In recent years, there have been significant changes in the Korean hospital nursing care delivery system. "Comprehensive nursing service," in which nurses provide direct care to patients, including activities of daily living without a family member, is one of the changes in the nursing profession's scope of practice. Accordingly, this study attempts to determine how well the electronic nursing record reveals nursing services that are being used differently. This study analyzed 19 372 nursing records of a total of 200 patients using the random sampling method in two comprehensive nursing service wards and two noncomprehensive nursing service wards. The number of nursing activity records for all items in the comprehensive nursing service ward was higher; only three items showed significant differences. Five nursing diagnoses including "anxiety" and "pain" were more significantly used in the records of the comprehensive nursing service ward. This study found that there were significant differences in nursing records based on the nursing services provided and that the current electronic nursing recording system adequately reflects changes in nursing practice.
Full Text
https://journals.lww.com/cinjournal/Fulltext/2020/06000/Assessing_How_Well_Electronic_Nursing_Records.7.aspx
DOI
10.1097/CIN.0000000000000585
Appears in Collections:
3. College of Nursing (간호대학) > Dept. of Nursing (간호학과) > 1. Journal Papers
Yonsei Authors
Park, Hyun Bong(박현봉)
URI
https://ir.ymlib.yonsei.ac.kr/handle/22282913/190068
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