Evaluation of the completeness of the nursing process for patients having gastrectomy using electronic nursing records.
The purpose of this study was to evaluate recording completeness of the nursing process. We compared nursing statements documented at the time when the Electronic Nursing Record (ENR) system, based on the ICNP, was implemented in 2004 with those documented in 2007. The ENRs for 35 gastrectomy patients in each year were selected for evaluation. The selected data were 11,822 nursing statements in 2004 and 27,870 in 2007. The results indicated a significant increase in the completeness of the nursing process in 2007. In addition, the number of nursing diagnosis increased by 5.1 times. The most contributing factor for this increase is assumed to be nurse education.
Park
Ihn-Sook
IS
Nursing Information committee, Seoul National University Hospital, Seoul, Korea. ihnsookp@snuh.org
Yoo
Cheong-Suk
CS
Joo
Young-Hee
YH
Woo
Kyung-Shun
KS
Choi
Woan-Heui
WH
Kang
Hyun-Sook
HS
Jung
Mi-Ra
MR
Kim
Hee-Jin
HJ
Lee
Su-Hee
SH
Ahn
Seon-Yeong
SY
Park
Mi-Ok
MO
D005069:Evaluation Studies as Topic; D005743:Gastrectomy / Q000451:nursing*; D006801:Humans; D016347:Medical Records Systems, Computerized; D009736:Nursing Process / Q000592:standards*