A Study on Knowledge, Importance and Performance in Nursing Records of University Hospital Nurses

Hwang, Eun Sook; Lee, So Jung; Ja, Kim， Sin; Hui, Heo， In

doi:10.34250/jkccn.2019.12.1.71

Cited by 3 publications

(1 citation statement)

References 9 publications

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“…Medical staff cannot communicate effectively without proper nursing records, and poor communication can negatively affect patient care. Therefore, nurses must ensure that their documentation meets high standards and must record treatment decisions and plans, nursing services provided, and patient's response to treatment [10,11].…”

Section: Introductionmentioning

confidence: 99%

Effects of nursing record education focused on legal aspects at small and medium sized hospitals

Kim

2021

J Korean Acad Soc Nurs Educ

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Purpose: The purpose of this study was to examine the effect of nursing record education on the knowledge and performance of nursing record of nurses at small- and medium-sized hospitals.Methods: The participants were 62 nurses working in two small- and medium-sized hospitals. Thirty-two nurses comprised the experimental group, and 30 nurses comprised the control group. Nursing record education was provided for the experimental group. Data were analyzed by x2-test and t-test analysis using the IBM SPSS statistics 25.0 Program. Results: After education, the knowledge (t=2.43, p=.019), performance (t=2.19, p=.033) and behavior scores (t=2.42, p=.018) on nursing record were significantly higher in the experimental group than in the control group. Based on this result, nursing record education is an effective intervention to improve nurses’ knowledge and performance in writing nursing records in small- and medium-sized hospitals. Conclusion: We suggest the development of a systematic and standardized education program on nursing record including its legal aspects, for nurses in small- and medium-sized hospitals. The results of this study can be used as basic data for developing a nursing record education program for small- and medium-sized hospitals.

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Section: Introductionmentioning

confidence: 99%

Effects of nursing record education focused on legal aspects at small and medium sized hospitals

Kim

2021

J Korean Acad Soc Nurs Educ

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Completeness of Patient Care Report (PCR) by Paramedics

Lee

Kim

Yun

2022

JICCE

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This study evaluated the completeness of patient care report (PCR). A retrospective quality analysis was conducted using raw data of 122,140 EMS activity reports prepared by paramedics in Gyeonggi-do from April 1 to May 31, 2021. In all, 67,830 cases of normal transfers were statistically analyzed using IBM SPSS Statistics version 22, and statistical significance was set at p <0.5. The 119EMT_2 certificate was omitted in 50,037 (73.8%) cases, followed by time-related items in 1,227 (1.8%) cases. In the primary assessment of vital signs, systolic blood pressure was omitted and erroneous in 1,218 (1.9%) and 1,129 (1.8%) cases, respectively. In the secondary assessment, the completeness of all vital sign items was approximately 70%. Advanced emergency care and online medical control (OLMC) reporting showed discrepancies in all items. As the severity of the patient's condition increased, the errors in the Patient care report (PCR) also increased, at a significant level (p= .00). Paramedics must be aware of the importance of completing the activity report.

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Experiences of Recording Electronic Nursing Notes among Ward Nurses in Two Hospitals

Hwang,

Kim,

Song

2024

J Korean Acad Fundam Nurs

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Purpose: This study explored the experiences of recording electronic nursing notes among ward nurses in the hospital. Methods: A qualitative descriptive study was conducted. Data were collected through in-depth interviews with 15 nurses at two university hospitals in Daegu between November 2022 and April 2023. Hsieh and Shannon’s conventional content analysis method was applied, and MAXQDA was used for the analysis. Results: Three categories were identified from the data, with 12 subcategories and 46 codes. The three categories were as follows: utility, limitations to effective use, and seeking a way to expand functions efficiently. Conclusion: Records involving electronic nursing notes played a very important role in patient care and legal protection, as well as serving as a guide to nursing diagnosis, a source of pride, and a resource with convenient functions. Areas for improvement relate to awareness, burden, discomfort, disparities, and obstacles to record-keeping. A more efficient record system needs to be established, with corresponding education. Furthermore, hospital administrators should provide policy support to improve the quality of nursing records.

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A Study on Knowledge, Importance and Performance in Nursing Records of University Hospital Nurses

Cited by 3 publications

References 9 publications

Effects of nursing record education focused on legal aspects at small and medium sized hospitals

Effects of nursing record education focused on legal aspects at small and medium sized hospitals

Completeness of Patient Care Report (PCR) by Paramedics

Experiences of Recording Electronic Nursing Notes among Ward Nurses in Two Hospitals

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