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J Korean Acad Nurs. 2005 Jun;35(3):441-450. Korean. Original Article. https://doi.org/10.4040/jkan.2005.35.3.441
Choi JY , Jang KS .
College of Nursing, Chonnam National University, Chonnam Research Institute of Nursing Science, Korea. choijy@jnu.ac.kr
Abstract

PURPOSE: The purposes of this study were to determine the core nursing interventions in nursing notes and the practice which was perceived by nurses of an oncology unit with patients with terminal cancer. Also, comparing interventions in nursing notes with interventions in perceived practice was done. METHOD: Subjects were 44 nursing records of patients with terminal cancer who had died from Jan. to Dec. 2002 at C University Hospital and 83 nurses who were working on an oncology unit for more than one year. Data was collected using a Nursing Interventions Classification and analyzed by means of mean and t-test. RESULTS: The most frequent nursing intervention was 'nausea management' in the nursing note and was 'medication administration : oral' in perceived practice. The frequency of nursing interventions in the nursing record was lower than in perceived practice. CONCLUSION: This study finds that nurses actually practice nursing care, but they may omit records. To correct for omitted nursing records, development of a systematic nursing record system, continuous education and feedback is recommended.

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