J Nurs Acad Soc.  1974 May;4(1):22-37.

A STUDY ON NURSING RECORD BEHATIOR REVEALED IN PATIENT'S RECORDS

• Kang YH

Abstract

Through the examination of hospitalized patient's records, this study purports to determine-the extent to which nursing record behaviors meet general expectations held for nursing records and the differences in nursing record behavior in relation to different nursing categories, period of recording and hospitals with different management patterns. Nursing record behaviors of 802 patient's records in four hospitals in Seoul were examined by use of a check list, which was prepared by the author as an instrument for the study. Data obtained from this examination were processed into percentage values for percentage test and chi-square test in order to determine their significance. Results are as follows; 1. Records pertaining to treatment ranked highest among all care categories in their extent of coverage, averaging 65.6 percent. 2. Of the treatment category records, records of medication led others at 94.3 percent, followed by records of test and collection of specimens at 59.9 percent, diet at 58.8 percent and treatment at 41.0 percent. 3. Records in the category of physical assessment and care averaged 44.1 percent, the second highest next to treatment category records. 4. Of the records in the category of physical assessment and care, records in vital signs placed first at 98.9 percent, followed by sleep at 76.2 percent, body weight at 74.7 percent, symptoms and signs at 69.3 percent, rest at 44.5 percent, hygiene at 39.7 percent, activities and partcipation at 16.9 percent, positions at 10.3 percent, level of consciousness at 9.8 percent and physiological dysfunction at 1.1 percent in that order. 5. Records in the category of psychosocial assessment and care averaged 3.2 percent, the lowest of the-three major categories. 6. Of the records in the category of psychosocial assessment and care, records on emotional responses ranked top at 10. 5 percent, followed by self-concern at 2.1 percent, adjustment at 2.0 percent, family, occupational and social relations at 0.7 percent and preferences, and interests at 0.5 percent in that order. 7. Records in relation to the category of specific conditions were found in 9.1 percent of the total records. 8. Of the records in the category of specific conditions, consuitation and transfer records, stood first at 25.0 percent, followed by precautionary measurements at 1.4 percent and isolation at 0.9 percent 9. A great difference in nursing record behavior was observed between the first week of hos-pitalization and the last week, with the first week's recordings much higher than the last week in the categories of treatment and specific conditions (p<0.01), and of physical assessment and care (p<0.05). 10. A big difference was also observed among the hospitals (p<0.01). 11. A big difference was also observed between the government-run hospitals and the private hospitals in the categories of physical assessment and care and specific conditions in the first week of hospitalization (P<0.05), and in the category of psychosocial assessment and care in the last week (P<0.05). 12. Between the hospitals established with foreign aid and the other hospitals, the difference in nursing record behavior was significant only in the category of physical assessment and care both in the first week and the last week (P<0.01). 13. The average nursing record behavior in all care categories stood at 45.1 percent in the extent of its coverage in relation to the general expectations.

MeSH Terms

Body Weight
Consciousness
Diet
Hospitalization
Hospitals, Private
Humans
Hygiene
International Cooperation
Nursing Records*
Nursing*
Seoul
Vital Signs