J Korean Soc Med Inform.  2005 Mar;11(1):45-55.

Analysis of Nursing Records of Cardiac Surgery Patients Based on Nursing Process Focusing on Nursing Outcome

• Kim YJ
• Park HA

Abstract

OBJECTIVES
The objective of this study is to find out what nurses wrote in narrative nursing notes.
METHODS
Forty-six patients' nursing notes were analyzed based on the nursing process. Eight patterns were extracted depending on the different combinations of the nursing process components.
RESULTS
Of the 8 patterns, assessment only pattern was the most frequent comprising 45.8% and assessment or diagnosis-intervention-outcome patterns accounted for 25.9% of the total nursing phrases. The content of nursing notes was also classified into 15 categories. Out of these 15 categories, nursing outcomes were recorded more frequently in nursing care mainly driven by doctor's order such as diseases related symptom management, insomnia care, respiratory care and pain control than in independent nursing care such as education and emotional care. According to the survey on nurses' attitude toward nursing record, nurses did not document nursing outcome as much as they reported they did. The main reasons for this discrepancy were insufficient time for recording and lack of knowledge about why, how and what to evaluate.
CONCLUSION
Even though there is room for improvement, nursing notes can be used a source for nursing contribution to patient outcomes.

Keyword

Nursing records; Nursing process; Nursing documentation; Nursing outcome; ICNP; Outcomes research

MeSH Terms

Education
Humans
Nursing Care
Nursing Process*
Nursing Records*
Nursing*
Outcome Assessment (Health Care)
Sleep Initiation and Maintenance Disorders
Thoracic Surgery*