Quality Evaluation of Nursing Observation Based on a Survey of Nursing Documents Using NursingNAVI? Contents in JAPAN

摘要

We have identified three foci of the nursing observation and nursing action respectively. Using these frameworks, we have developed the structured knowledge model for a number of diseases and medical interventions. We developed this structure based NursingNAVI? contents collaborated with some quality centred hospitals. Authors analysed the nursing care documentations of post-gastrectomy patients in light of the standardized nursing care plan in the "NursingNAVI?" developed by ourselves and revealed the "failure to observe" and "failure to document", which leaded to the volatility of the patients' data, conditions and some situation. This phenomenon should have been avoided if nurses had employed a standardized nursing care plan. So, we developed thinking process support system for planning, delivering, recording and evaluating in daily nursing using NursingNAVI? contents. It is important to identify the problem of the volatility of the patients' data, conditions and some situation. We developed a survey tool of nursing documents using NursingNAVI? Content for quality evaluation of nursing observation. We recommended some hospitals to use this survey tool. Fifteen hospitals participated the survey using this tool. It is estimated that the volatilizing situation. A hospital which don't participate this survey, knew the result. So the hospital decided to use NursingNAVI? contents in HIS. It was suggested that the system has availability for nursing OJT and time reduction of planning and recording without volatilizing situation.