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J Korean Wound Management Soc > Volume 5(2); 2009 > Article
Journal of the Korean Wound Management Society 2009;5(2): 94-97.
가정간호 기록에서 나타난 상처간호 개념 분석
김지현ㆍ박현애
서울대학교 간호대학
Analysis of Wound Care Concepts in Home Health Care Documentation
Jihyun Kim, Hyun Ae Park
College of Nursing, Seoul National University, Seoul, Korea
  Published online: 30 November 2009.
ABSTRACT
Patient record is the most important tool in the evidence of home care services by nurse and for communication among multiple disciplinary domain experts. The purpose of research is to analysis for wound care concept in home health care documentation and to propose a method for efficient wound care recording. Nursing concepts from home care documentation were selected, and matched to Omaha system. Wound care concepts were defined and selected by categorizing "impaired skin integrity" and "skin". The most concept in wound care intervention concepts was "treatments and procedure" and the most concept in wound care problem concepts was "rash". Concepts from home care record had high abstraction and few detailed representing components. For improving quality and accuracy of nursing record, the standardized and structured nursing documentation is critical. And the electronic nursing record has the potential to support the reusability of data in that documentation. (J Korean Wound Management Soc 2009;5:94-97)
Key Words: Standard nursing terminology, Wound care documentation, Home care nursing
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