Formative Evaluation of Standard Terminology-based Electronic Nursing Record System in Clinical Setting

Cho, Insook; Park, H A; Chung, Eun‐Jae; Lee, H S

doi:10.4258/jksmi.2003.9.4.413

Cited by 2 publications

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“…However, in order to use such electronic medical records more efficiently, and to facilitate the smooth sharing and exchange of information between systems and medical institutions, it is imperative for an electronic medical record system to be based on a controlled vocabulary [ 3 ]. In nursing, an electronic nursing records system based on International Classification for Nursing Practice (ICNP), a controlled nursing vocabulary, was introduced in early 2003 in Korea [ 4 ], and went so far as to use the data gathered using this system in decision-making and research [ 5 ]. But in the case of physicians' records, only fragmentary information such as chief complaints [ 6 ], decision-making rules [ 7 ], discharge summaries, diagnoses, and operation names [ 3 ] has been mapped to Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT).…”

Section: Introductionmentioning

confidence: 99%

Exploring the Possibility of Information Sharing between the Medical and Nursing Domains by Mapping Medical Records to SNOMED CT and ICNP

Park

2011

Healthc Inform Res

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ObjectivesThe purpose of this study is to explore possibility of information sharing between the medical and nursing domains.MethodsNarrative medical records of 281 hospitalization days of 36 gastrectomy patients were decomposed into single-meaning statements. These single-meaning statements were combined into unique statements by removing semantically redundant statements. Concepts from the statements describing patients' problem and medical procedures were mapped to Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) and International Classification for Nursing Practice (ICNP) concepts.ResultsA total 4,717 single-meaning statements were collected and these single-meaning statements were combined into 858 unique statements. Out of 677 unique statements describing patients' problems and medical procedures, about 85.5% statements were fully mapped to SNOMED CT. The remaining statements were partially mapped. In the mapping to the ICNP concepts, 17.4% of unique statements were fully mapped, 62.8% were partially mapped, and 19.8% were not mapped. About 32.3% of 705 concepts extracted from the statements were mapped to both SNOMED CT and ICNP concepts.ConclusionsThese mapping results suggest that physicians' narrative medical records can be structured and can be used for electronic medical record system, and also it is possible for medicine and nursing to share patient care information.

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Section: Introductionmentioning

confidence: 99%

Exploring the Possibility of Information Sharing between the Medical and Nursing Domains by Mapping Medical Records to SNOMED CT and ICNP

Park

2011

Healthc Inform Res

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Shortening of Nursing Record Time about Real Time Transmission Effect of Blood Pressure, Blood Glucose Value Based on U-Healthcare

Park¹,

Kim²,

Hong

2013

Journal of Korean Biological Nursing Science

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Purpose:The aim was to measure the real-time trans-mission effect of blood-pressure and blood-glucose value based on u-healthcare for saving the time and effort of nursing recording time. Methods: This study used a u-healthcare system based on the international standards for the exchange of health information. In order to verify the effectiveness of the u-healthcare, a clinical trial for the system regarding blood-pressure and blood-glucose targeting of patients with endocrine disorders at KNUH from February 7 to 9, 2012 was performed. Results: According to the analyzed results, of the 86 times the 11 patients were tested, measuring blood-pressure and blood-glucose using the u-healthcare system, we found the time differences between the real-time transfer recording method and existing hospital records that were used in the hospital. Based on the average time interval, there was a difference of 1,090.45 seconds (18.17 minutes). Conclusion: Therefore, it' s cumbersome that nurses in the hospital have to record the numerical values of the measured blood-pressure and blood-glucose manually and input the recorded values directly into the electronic nursing record system. However, it was found in terms of the newly designed system, that it could save time and effort for nurses, since measured information is sent to the hospital information system on a real-time basis.

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Formative Evaluation of Standard Terminology-based Electronic Nursing Record System in Clinical Setting

Cited by 2 publications

References 0 publications

Exploring the Possibility of Information Sharing between the Medical and Nursing Domains by Mapping Medical Records to SNOMED CT and ICNP

Exploring the Possibility of Information Sharing between the Medical and Nursing Domains by Mapping Medical Records to SNOMED CT and ICNP

Shortening of Nursing Record Time about Real Time Transmission Effect of Blood Pressure, Blood Glucose Value Based on U-Healthcare

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