Idvall Ewa, Ehrenberg Anna
Department of Medicine and Care, Division of Nursing Science, Faculty of Health Sciences, Linköping University, Linköping and Västervik Hospital, Västervik, Sweden.
J Clin Nurs. 2002 Nov;11(6):734-42. doi: 10.1046/j.1365-2702.2002.00688.x.
Previous studies have shown that nursing documentation is often deficient in its recording of pain assessment and treatment. In Sweden, documentation of the care process, including assessment, is a legal obligation. The aim of this study was to describe nursing documentation of postoperative pain management and nurses' perceptions of the records in relation to current regulations and guidelines. The sample included nursing records of postoperative care on the second postoperative day from 172 patients and 63 Registered Nurses from surgical wards in a central county hospital in Sweden. The records were reviewed for content and comprehensiveness based on regulations and guidelines for postoperative pain management. Three different auditing instruments were used. The nurses were asked if the documentation concurred with current regulations and guidelines. The result showed that pain assessment was based mainly on patients' self-report, but less than 10% of the records contained notes on systematic assessment with a pain assessment instrument. Pain location was documented in 50% of the records and pain character in 12%. About 73% of the nurses reported that the documentation concurred with current regulations and guidelines. The findings indicate that significant flaws existed in nurses' recording of postoperative pain management, of which the nurses were not aware.
以往研究表明，护理记录在疼痛评估和治疗记录方面常常存在不足。在瑞典，包括评估在内的护理过程记录是一项法定义务。本研究的目的是描述术后疼痛管理的护理记录以及护士对这些记录与现行法规和指南相关性的看法。样本包括瑞典一家中心县医院外科病房172例患者术后第二天的护理记录以及63名注册护士的记录。根据术后疼痛管理的法规和指南，对记录的内容和完整性进行了审查。使用了三种不同的审核工具。询问护士这些记录是否符合现行法规和指南。结果显示，疼痛评估主要基于患者的自我报告，但不到10%的记录包含使用疼痛评估工具进行系统评估的记录。50%的记录记录了疼痛部位，12%记录了疼痛性质。约73%的护士报告说这些记录符合现行法规和指南。研究结果表明，护士在术后疼痛管理记录方面存在重大缺陷，而护士并未意识到这些缺陷。
