J Nurs Acad Soc.  1980 Dec;10(2):87-94.

The Nursing Record Evaluation of the Application of the Nursing Process

• Lee KH
• Kim MS

Abstract

According to the provious study, it was suggested a need for improvement of nursing care through application of nursing process in Ewha Womans University Hospital With those data, it has been applied to the nursing care at maternity ward by nurses. This study was undertaken to determine the evaluation of the application of the nursing process which is an orderly, systemic manner of determing the patient's /client's nursing problems. This study involved 191 cases with patient chart and was carried out from Feb. 1979 to Feb. 1980 is Ewha Womans University Hospital. The results were as follows : 1. Actual performance of "Assessment" stage was 59%, and 45% for the nursing diagnosis. 2. It was achieved with specific planning of nursing; care for 71.6% and the plan was safely and effective implemented (97.9%). 3. Afer "Implement" stage it was made of evaluation and feedback process (39%). 4. Nurses in Eha womans University hospital, they showed the positive attitude toward the application of nursing process, but they saggested that there were lack of manpower and the consideration of time allocation. Recommandation are as follows : 1. All nursing staff must participate in continious education program for nursing process. 2. The results suggest a need for modification for the nursing history formeat and SOAPIER. 3. A need for improvement of physical condition for interview and effective utilization of nursing staff. 4. It Will more effective When Dr's medical record replace by problem arientcd acdical record(POMR).

MeSH Terms

Education
Female
History of Nursing
Humans
Medical Records
Nursing Care
Nursing Diagnosis
Nursing Process*
Nursing Records*
Nursing Staff
Nursing*