병원간호사의 간호기록 작성방법에 대한 지식측정도구 개발 -법적인 관점에서

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.