[Comparison of nursing activities reflected in nursing notes and in-depth interviews of nurses in an acute hospital].
OBJECTIVE
The purpose of this study was to compare the nursing activities delineated by interview of nurses with those on nursing notes.


METHODS
The participants of interview were 18 nurses working in medical and surgical units of a large hospital in Seoul. Each nurse was asked to choose one patient who demand most nursing care among her patients. The nurse was then interviewed to describe what her nursing activities for the patient was that day. The audio-taped interview was transcribed and the content was analyzed by researchers. Nursing notes of each nurses' patients were copied and the content analyzed by researchers. Finally, themes from the interview data and those from nursing notes were compared.


RESULTS
Activities related to emotional or psychological nursing, education for patient and families, and problem solving related to treatment or nursing procedure were most often omitted in nursing notes. Most of the documentation in nursing notes were related to physical condition of patients or physician's orders. Nurses described that they will do better recording if they were given less patient care responsibility, had better nursing knowledge, had better recording system, and received more training on nursing record.


CONCLUSIONS
Nursing notes did not reflect nursing activities properly. Few independent nursing roles were documented in the nursing notes. Development of nursing education program and nursing record system is needed for improvement of nursing record.
College of Nursing, Seoul National University, Korea. msong@snu.ac.kr
Misoon
M
Song
Mae-Ja
MJ
Kim
Young Sook
YS
Park
Eun-Ok
EO
Lee
Yang-Sook
YS
Hah
Kyung-Ja
KJ
Han
Se-Ang
SA
Ryu
Hae-Young
HY
Kang
Kyung-Nam
KN
Kim
Moon-Sook
MS
Cho