Park Hyeoun-Ae, Cho Insook, Ahn Hee-Jung
College of Nursing, Seoul National University, Seoul, South Korea;
NI 2012 (2012). 2012 Jun 23;2012:316. eCollection 2012.
To explore the usefulness of narrative nursing records documented using a standardized terminology-based electronic nursing records system, we conducted three different studies on (1) the gaps between the required nursing care time and the actual nursing care time, (2) the practice variations in pressure ulcer care, and (3) the surveillance of adverse drug events. The narrative nursing notes, documented at the point of care using standardized nursing statements, were extracted from the clinical data repository at a teaching hospital in Korea and analyzed. Our findings were: the pediatric and geriatric units showed relatively high staffing needs; overall incidence rate of pressure ulcer among the intensive-care patients was 15.0% and the nursing interventions provided for pressure-ulcer care varied depending on nursing units; and at least one adverse drug event was noted in 53.0% of the cancer patients who were treated with cisplatin. A standardized nursing terminology-based electronic nursing record system allowed us to explore answers to different various research questions.
为探究使用基于标准化术语的电子护理记录系统记录的叙事性护理记录的实用性,我们针对以下三个方面开展了三项不同的研究:(1)所需护理时间与实际护理时间之间的差距;(2)压疮护理中的实践差异;(3)药物不良事件监测。叙事性护理记录采用标准化护理陈述在护理现场进行记录,从韩国一家教学医院的临床数据存储库中提取并进行分析。我们的研究结果如下:儿科和老年科病房显示出相对较高的人员配备需求;重症监护患者中压疮的总体发生率为15.0%,针对压疮护理所提供的护理干预因护理单元而异;在接受顺铂治疗的癌症患者中,53.0%的患者至少发生过一次药物不良事件。基于标准化护理术语的电子护理记录系统使我们能够探索不同研究问题的答案。