Ehrenberg Anna, Birgersson Christina
Department of Health and Society, Dalarna University, Falun, Sweden.
Scand J Caring Sci. 2003 Sep;17(3):278-84. doi: 10.1046/j.1471-6712.2003.00231.x.
The aim of this study was to investigate the adherence of nursing documentation to clinical guidelines in leg ulcer patients. Using two audit instruments, 100 patient records from primary health care were reviewed. The nursing content in the records was assessed according to instructions for documentation in local clinical guidelines for leg ulcers and the comprehensiveness of the nursing process in recording was reviewed. The results indicated deficiencies in the documentation of aspects of relevance in the care of leg ulcer patients. In addition, the findings indicated flaws in the adoption of the nursing process in recording. Only one problem in one patient record was recorded that consistently used the nursing process. The conclusion is that, despite specific and locally developed guidelines for care of leg ulcer patients, nursing records did not provide a precise audit of the care process. Because patient record information without a clear structure following the nursing process tends to impede communication and evaluation of care, such defective information is likely to have a significant impact on the continuity and quality in patient care.
本研究的目的是调查腿部溃疡患者护理记录与临床指南的符合情况。使用两种审核工具，对来自初级卫生保健机构的100份患者记录进行了审查。根据当地腿部溃疡临床指南中的记录说明，对记录中的护理内容进行了评估，并审查了记录中护理过程的全面性。结果表明，在腿部溃疡患者护理相关方面的记录存在不足。此外，研究结果还表明在记录中采用护理过程存在缺陷。在100份患者记录中，只有一份记录中的一个问题始终采用了护理过程。结论是，尽管有针对腿部溃疡患者护理的具体且本地化制定的指南，但护理记录并未对护理过程进行精确审核。由于缺乏遵循护理过程的清晰结构的患者记录信息往往会妨碍护理的沟通和评估，这种有缺陷的信息很可能对患者护理的连续性和质量产生重大影响。
