정신과 병동의 간호업무 효율성을 위한 간호기록 도구 개발 = A Study on the Development on Nursing Record for Effective Nursing Practice in Psychiatric Ward

다국어 초록 (Multilingual Abstract)

The purpose of this study is to establish and to practice the effective nursing care, to improve nursing activities and the bedside of nursing.
During the past few years many studies have remarked that nurse spend less and less time at the bediside, largely because they have been busy with other time-consuming activities such as charting notes.
If charting time could be reduces, the nurses would have more time for the patients.
Yet clear, concise, and accurate charting is essential.
We decided to review nursing recording methods.
Firstly, we identified that nursing record contents and pattens in recent years through 30 charts of nursing record of the psychiatric words, in three of university hospitals. Most of that was descriptive and repeated which we confirmed. Also the data was devided by meaning and content. We developed our work with record of the behavior observation record.
24 of psychiatric nurse specialists found the content validity with high score.
Form 1995, July 1 to July 3(three days), pre-testing of behaviour observation record tool was done at one of sample psychiatric hospitals.
Then it was modified to 14 items by psychiatrists and psychiatric nurses.
The 14 items are delow ;
1. personal hygiene
2. psychiatrist's rounding
3. activity therapy
4. walking
5. meals
6. wandering in the ward
7. ward activity
9. visiting hour
10. interview
11. sleeping
12. laboratory exam
13. consultation to other department
14. special treatment
Form Aug 1 to 20(20 days), we applied to 50 of inpatient with recorrected tools.
There were some limitations which are lack of explanations of need for a special form. for example, acting-out patient, suicide attempt patient, special demending patient and patients in seclusion room. Because of this limitation, we decided to include the old nursing record for more effectivity.
With this research, some of nurses remarks were ; "Very compart and much better than the old form.", "Save a lot of time-less waste of paper.", "New form is more efficient, concise and saves time."