SHERP

병원간호사의 간호기록 작성방법에 대한 지식측정도구 개발 -법적인 관점에서
A Nurse Charting Knowledge Scale : Focusing on Legal Aspects

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Authors
김영미; 박성애
Issue Date
2007
Publisher
병원간호사회 = Hospital Nurses Association
Citation
임상간호연구, 13(2), 27-38
Keywords
간호기록지식Nurse chartingKnowledgeLaw
Abstract
Purpose: The purpose of this study was to develop an instrument to measure nurses’ knowledge about charting and
charting principles. Methods: Twenty six key attributes of nurse charting were identified by concept analysis of relevant
literatures as well as nurse manager definitions and served as the basis for the development of a 65-item survey
instrument. The Nurse Charting Knowledge Scale(NCKS) was validated by a panel of experts for its content and pilot
tested in 23 nurses. Then we administered the NCKS to a convenience sample of 252 nurses on a medical nursing
units in a tertiary hospital in Seoul, Korea. Data were collected from July 11th to July 25th, 2006. This article
describes the psychometrics and validity of the NCKS using data from the final sample of 250 nurses. Results: The 26
key attributes of nurse charting were divided into two categories of do's and don'ts through concept analysis. The
dimension of do's included identity, timeliness, completeness, accuracy, objectiveness, specification, honesty, relevance,
information producibility, evidence producibility, accessibility and intactability. The dimensions of dont's included
recording staffing problems, recording staff conflicts, naming a second patient, charting casual conversations with
colleagues, assuming that computer charting contains every information from the patient's written chart, subjectively
labeling the patient's behavior, using a language that suggests a negative attitude toward the patient, using inappropriate
comments, using inappropriate language, mentioning incident reports, using words associated with errors, using comments
implying that the patient's complaints are groundless, implying negligence and concealing or overstating medical mishaps.
The NCKS was found to have acceptable reliability(internal consistency, KR 20 coefficient = 0.73). Conclusion: The
NCKS shows promise as a measure of nurses’ knowledge about charting. The instrument can be readily adapted as a
tool to educate nurses about the importance of nurse charting and charting principles.
ISSN
1598-9186
Language
Korean
URI
http://hdl.handle.net/10371/9652
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College of Nursing (간호대학)Dept. of Nursing (간호학과)Journal Papers (저널논문_간호학과)
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