[Analysis of the nursing practice in a medical ICU based on an electronic nursing record].
OBJECTIVE
The purpose of this study was to identify the entity of critical care nursing practices through analyzing nursing statements described by electronic nursing records in a MICU.


METHODS
176,459 nursing statements of 188 patients during a 6 month-stay were analyzed statement by statement according to the nursing process(nursing phenomena, nursing diagnosis, & nursing activity) and 21 nursing components of Saba's Clinical Care Classification.


RESULTS
Among 176,459 single statements, the statements of nursing activity ranked first in number. The contents of the statements were analyzed and categorized by main themes. Among 489 categorized themes, the number of themes of nursing phenomena statements was the highest. When analyzed by Saba's clinical Care Classification, the nursing statements mainly included a physiological component. Among 21 components, the respiratory component ranked in the first position in nursing phenomena, nursing diagnosis and nursing activity. The extra statements not included in the 21 components were 9,294(15.1%) in nursing phenomena and 21,949(22.7%) in nursing activity. Most are statements related to tests and the doctor.


CONCLUSIONS
The entity of MICU nursing practice expressed by electronic nursing records was mainly focused on physiological components and more precisely on respiratory components.
Song
Kyung Ja
KJ
Seoul National University Hospital, Chongno-Gu, Seoul, Korea. icusong@hanmail.net
D006801:Humans; D007362:Intensive Care Units; D016347:Medical Records Systems, Computerized / Q000706:statistics & numerical data*; D009733:Nursing Diagnosis; D009736:Nursing Process / Q000145:classification*; D012189:Retrospective Studies; D013647:Task Performance and Analysis