Moldanado S A
J Community Health Nurs. 1991;8(3):171-8. doi: 10.1207/s15327655jchn0803_7.
Documentation of high-risk infant (HRI) encounters in the nursing flowsheet by public health nurses (PHNs) at a county health department is evaluated for its effectiveness. A convenience sample of 31 client records was used. The effectiveness in documentation was evaluated in terms of PHNs' adherence to guidelines provided for the use of the particular nursing flowsheet. The frequency of correct documentation was determined for assessment, intervention, and outcome measures. Within the category of assessment, a high rate of correct documentation was found for the items, elimination, and bonding status. A moderate rate of correct documentation was noted for items pertaining to physical assessment, health-care system used, child abuse and neglect potential in the home, and safety. Documentation of anticipatory guidance or intervention provided was minimal throughout the flowsheet. The outcome measures, expressed as goal statements, were by comparison, more often documented correctly.
对某县卫生部门的公共卫生护士（PHN）在护理流程表中记录高危婴儿（HRI）情况的有效性进行了评估。使用了31份客户记录的便利样本。根据PHN对特定护理流程表使用指南的遵守情况来评估记录的有效性。确定了评估、干预和结果测量方面正确记录的频率。在评估类别中，发现关于排泄和母婴联结状况等项目的正确记录率很高。对于与体格检查、使用的医疗保健系统、家庭中儿童虐待和忽视的可能性以及安全相关的项目，正确记录率中等。在整个流程表中，预期指导或干预的记录很少。相比之下，以目标陈述形式表达的结果测量更常被正确记录。
