探寻护理记录中患者教育的细节——对瑞典一家内科病房患者记录的分析
In search of details of patient teaching in nursing documentation--an analysis of patient records in a medical ward in Sweden.
作者信息
Friberg Febe, Bergh Anne-Louise, Lepp Margret
机构信息
School of Health Sciences, University College of Borås, Borås, Sweden.
出版信息
J Clin Nurs. 2006 Dec;15(12):1550-8. doi: 10.1111/j.1365-2702.2006.01586.x.
AIM
The aim of this study was to identify terms and expressions indicating patients' need for knowledge and understanding, as well as nurses' teaching interventions, as documented in nursing records.
BACKGROUND
Previous international studies have shown that nursing documentation is often deficient in terms of recording patient teaching.
METHODS
Patient records (N = 35) were collected in a general medical ward in a hospital in Sweden. The data contain 206 days of nursing documentation. The records were analysed with regard to content and structure. Terms and expressions indicating patients' need for knowledge and understanding and terms and expressions indicating nurses' teaching activities were analysed.
RESULTS
The results showed that patients' need for knowledge is implicitly indicated by conceptions and experiences as well as questions. Furthermore, nurses' implicit teaching interventions consist of information, motivating conversations, explanations, instructions and setting expectations. However, the content and structure of the pedagogical activities in the patient records are fragmented and vague.
RELEVANCE TO CLINICAL PRACTICE
Efforts must be directed towards elaborating upon the above-mentioned terms and expressions as indications of patients' need for knowledge and nurses' teaching interventions. Moreover, these terms and expressions must be recognized and acknowledged.
目的
本研究旨在识别护理记录中表明患者知识与理解需求的术语和表达，以及护士的教学干预措施。
背景
以往国际研究表明，护理记录在记录患者教学方面往往存在不足。
方法
在瑞典一家医院的普通内科病房收集患者记录（N = 35）。数据包含206天的护理记录。对记录的内容和结构进行分析。分析表明患者知识与理解需求的术语和表达以及表明护士教学活动的术语和表达。
结果
结果显示，患者的知识需求通过观念、经历以及问题隐含地体现出来。此外，护士的隐性教学干预包括信息提供、激励性对话、解释、指导和设定期望。然而，患者记录中教学活动的内容和结构零散且模糊。
与临床实践的相关性
必须努力详细阐述上述术语和表达，将其作为患者知识需求和护士教学干预的指标。此外，这些术语和表达必须得到认可和重视。
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