J Nurs Acad Soc.  1977 Jun;7(1):1-9.

An Experimental Study OB Implementation of Problem-Oriented Nursing Record

• Kang YH

Abstract

Primary function of health record is that as tool of communication between the health professionals with the mutual goal, the promotion of health care standard Studies have been carried out world over on the sabject, among those, Weed's Problem-Oriented Health Record is considered a paramount achievement. This study was designed to assess the possibility of implementing the problem-oriented health record system through an experiment in order to provide data for nurse administrators initiating reformation of recording system and format. Records of 29 patients admitted at Korea University Hospital, Seoul, from March thorugh June, 1976 for 4 to 14 days were sampled. Nursing notes were recorded by research assistants;senior nursing student trained extensively by the researcher on Problem-Oriented Records, on Problem Oriented Nursing Record format (experimental group) and analysis were carried out comparatively with that of traditional nursing records noted by other nursing personnel ( control group) on the same patient. Attitude towards Problem Oriented Nursing Record system and format were attained through questionaires responded by the 51 research assistants. Results are as follows: Comparative analysis revealed that: 1 . Assessment of patients' health problems recorded significantly more in traditional records. 2. Focus of health problem differed; traditional records showed significantly higher frequency in medical and procedure as focus while problem oriented records on nursing focus problems. 3. Problem-Oriented records were better organized, Mean value scores of attitude towards Problem-Oriented Records revealed that: Positive value scores on all 4 categories: 1) Assessment of nursing needs, 2) Nursing care planning 3) Patient progress assessment and 4) Tool of teaching and learning revealed that the Problem-Oriented Nursing Record is positively accepted by the respondents. Recommendations Further experiments on implementation of Problem-Oriented Health Record are recommended: experiment involving all health professionals, in larger scope and longitudinal.

MeSH Terms

Health Occupations
Health Promotion
Humans
Korea
Learning
Nurse Administrators
Nursing Records*
Nursing*
Patient Care Planning
Seoul
Standard of Care
Students, Nursing
Surveys and Questionnaires