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Objectives: The purpose of this study is to identify the differences between the integrated nursing care service and non integrated nursing care service through electronic nursing documentation. Methods: We retrospectively reviewed the electronic nursing documentation of 102 patients who were admitted to G general hospital for analyzing the frequency of nursing statements between the month of January 2016 and the month of January 2017 using random sampling. The data were analyzed using percentage, mean, standard deviation, chi-square test and independent t-test with the SPSS Win 23.0 Program. Results: The frequency of use for the nursing statements was investigated: there was a significant difference in nursing record on pain assessment (p< 0.001), nurse rounding, fall prevention (p= 0.001), rounding for voiding, oral medication counseling, skin assessment, oral care, cold pack apply, bath, shampoo, face wash and teeth brushing, meal assistance, hot pack apply and tube feeding (p< 0.001) between the integrated nursing care service and non integrated nursing care service. There was no significant difference in the frequency of nursing diagnosis. Conclusions: Results confirm that the nurse’s job had changed in the integrated nursing care service for example the direct patient care related in daily living assistance. Based on these results, the additional efforts to increase the records of patient education, counseling and emotional assessment are needed in order to improving the effective integrated nursing care service through job analysis.

Comparison Analysis between Integrated Nursing Care Service and Non Integrated Nursing Care Service through Electronic Nursing Documentation