Research Into the Way of Writing Nursing Diagnosis in Electronic Medical Records

2.50
Hdl Handle:
http://hdl.handle.net/10755/151991
Type:
Presentation
Title:
Research Into the Way of Writing Nursing Diagnosis in Electronic Medical Records
Abstract:
Research Into the Way of Writing Nursing Diagnosis in Electronic Medical Records
Conference Sponsor:Sigma Theta Tau International
Conference Year:2011
Author:Sugiura, Misako, PhD
P.I. Institution Name:Japanese Red Cross Toyota College of Nursing
Title:Professor
Co-Authors:Junko Okumura MMI, Professor
Setsuko Maeda MSN, Associate Professor
Takako Takeuchi MSN, Assistant Professor
Yayoi Watanabe MSN, Assistant
Kaori Nakajima MMS, Associate Professor
Toshinobu Kawai PhD, Associate Professor
Seiichiro Takami MBA, Assistant
[22nd International Nursing Research Congress - Evidence-based Practice Presentation] Purpose: In Japan, the conversion of nursing information to electronic form is rapidly progressing, and the number of medical institutions which adopt nursing diagnosis is increasing in order to describe patients? nursing problems in common terms.  However, the use of nursing diagnosis largely depends on the ability of nurses of judging nursing diagnosis and on the way of producing the menu of electronic medical records.  This research regards the ability of nursing diagnosis as a process, and shows how, in Japanese electronic records, diagnosis process in each level flows and contributes to the judgment of nursing diagnosis. 
Methods: The researchers obtained an approval from the Ethics Committee of the A University.  As regards research objects and methods, the researchers interviewed three persons in nursing departments responsible for electronic medical records in Japanese official hospitals and observed the introduced system.
Results: It is revealed from the research that the characteristics of each patient?  nursing diagnosis label are necessary for nursing practice which suits each patient.  Nursing diagnosis label, its related factors and diagnosis categories should be written down in nursing records. Furthermore, it should be guaranteed to describe, as etiologic factors and signs/symptoms, factors and signs/symptoms of the patients rather than the list of defining characteristics and related factors described by the North American Nursing Diagnosis Association (NANDA).
Repository Posting Date:
26-Oct-2011
Date of Publication:
17-Oct-2011
Sponsors:
Sigma Theta Tau International

Full metadata record

DC FieldValue Language
dc.typePresentationen_GB
dc.titleResearch Into the Way of Writing Nursing Diagnosis in Electronic Medical Recordsen_GB
dc.identifier.urihttp://hdl.handle.net/10755/151991-
dc.description.abstract<table><tr><td colspan="2" class="item-title">Research Into the Way of Writing Nursing Diagnosis&nbsp;in Electronic Medical Records</td></tr><tr class="item-sponsor"><td class="label">Conference Sponsor:</td><td class="value">Sigma Theta Tau International</td></tr><tr class="item-year"><td class="label">Conference Year:</td><td class="value">2011</td></tr><tr class="item-author"><td class="label">Author:</td><td class="value">Sugiura, Misako, PhD</td></tr><tr class="item-institute"><td class="label">P.I. Institution Name:</td><td class="value">Japanese Red Cross Toyota College of Nursing</td></tr><tr class="item-author-title"><td class="label">Title:</td><td class="value">Professor</td></tr><tr class="item-email"><td class="label">Email:</td><td class="value">sugiura@rctoyota.ac.jp</td></tr><tr class="item-co-authors"><td class="label">Co-Authors:</td><td class="value">Junko Okumura MMI, Professor<br/>Setsuko Maeda MSN, Associate Professor<br/>Takako Takeuchi MSN, Assistant Professor<br/>Yayoi Watanabe MSN, Assistant<br/>Kaori Nakajima MMS, Associate Professor<br/>Toshinobu Kawai PhD, Associate Professor<br/>Seiichiro Takami MBA, Assistant</td></tr><tr><td colspan="2" class="item-abstract">[22nd International Nursing Research Congress - Evidence-based Practice Presentation] Purpose: In Japan, the conversion of nursing information to electronic form is rapidly progressing, and the number of medical institutions which adopt nursing diagnosis is increasing in order to describe patients? nursing problems in common terms.&nbsp; However, the use of nursing diagnosis largely depends on the ability of nurses of judging nursing diagnosis and on the way of producing the menu of electronic medical records.&nbsp; This research regards the ability of nursing diagnosis as a process, and shows how, in Japanese electronic records, diagnosis process in each level flows and contributes to the judgment of nursing diagnosis.&nbsp; <br/>Methods: The researchers obtained an approval from the Ethics Committee of the A University.&nbsp; As regards research objects and methods, the researchers interviewed three persons in nursing departments responsible for electronic medical records in Japanese official hospitals and observed the introduced system. <br/>Results: It is revealed from the research that the characteristics of each patient?&nbsp; nursing diagnosis label are necessary for nursing practice which suits each patient.&nbsp; Nursing diagnosis label, its related factors and diagnosis categories should be written down in nursing records. Furthermore, it should be guaranteed to describe, as etiologic factors and signs/symptoms, factors and signs/symptoms of the patients rather than the list of defining characteristics and related factors described by the North American Nursing Diagnosis Association (NANDA).</td></tr></table>en_GB
dc.date.available2011-10-26T11:20:27Z-
dc.date.issued2011-10-17en_GB
dc.date.accessioned2011-10-26T11:20:27Z-
dc.description.sponsorshipSigma Theta Tau Internationalen_GB
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