J Korean Acad Adult Nurs.  2006 Sep;18(4):533-542.

Analysis of Medical Records and Development of Chest Pain Care Record in the Emergency Department

• Choi GY
• Moon YS
• Hong ES

Abstract

PURPOSE: The purposes of this study were to investigate medical records and to develop care records for management of patients with chest pain in the emergency department. METHOD: Retrospective review of the 42 medical chart of patients presented to the emergency department with chest pain were used. The collected data were analyzed with a frequency of items in the medical records.
RESULTS
In a frequency analysis of recorded items for doctors' chest pain assessment during history taking, the history/risk factors was the highest rank. The following ranks were 'commenced with when/ timing, extra symptoms, place, nature, stay/ radiate, alleviate/aggravate, intensity' in sequence. In a frequency of recorded items in nurse's progress notes according to nursing actions, the 'checking/monitoring' was the highest rank. The following ranks were 'performing, administering/injecting, referring/ arranging, testing, preparing/catheterizing, teaching/informing' in sequence. Chest pain care records for the emergency department was designed, based upon data analysis and literature review.
CONCLUSION
The designed records can be a rapid and effective approach tool for assessment and recording of patients with chest pain. Further research is necessary for evaluating the designed chest pain care records.

Keyword

Emergencies; Chest pain; Nursing records

MeSH Terms

Chest Pain*
Emergencies*
Emergency Service, Hospital*
Humans
Medical Records*
Nursing
Nursing Records
Retrospective Studies
Statistics as Topic
Thorax*