Ahlqvist Margary, Berglund Britta, Wirén Mikael, Klang Birgitta, Johansson Eva
Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm SE-14186, Sweden.
J Clin Nurs. 2009 Jul;18(13):1945-52. doi: 10.1111/j.1365-2702.2008.02778.x.
The aim was to explore the extent of postinsertion documentation of peripheral venous catheters (PVCs) in patients' medical records, including the descriptions used to explain the PVC insertion site and determinants of PVC documentation.
Documentation in medical records is an important precondition for the safe handling of patients PVC. However, factors associated with documentation of PVCs and how the insertion site is described in medical records has not previously been studied.
This was a cross-sectional and descriptive study.
A sample of 933 adult inpatients (women 45.7%) with PVC was recruited from medical and surgical wards at one university hospital and two general hospitals. A data collection form was used for registration of the insertion site of the PVC, hand side, lumen size, patient's age and gender. PVC documentation from medical records was transcribed. Factors associated with the documentation were analysed using logistic regression.
Ten descriptions used to explain the insertion site of the PVCs were identified in the patients' medical record. Any kind of PVC documentation was found in 71.8% and documentation that included insertion site, hand side and lumen size was recorded in 46.2% of the observed PVCs. Multivariate logistic regression revealed that PVC documentation was associated with medical wards at general hospitals (OR 4.59; 95% CI 3.10-6.81; p < 0.0001) and smaller lumen size (22 gauge) (OR 1.81; 95% CI 1.19-2.84, p = 0.006).
The extent of PVC documentation in medical records was low and descriptions used to explain the PVC insertion sites were found to vary appreciably. General hospitals and in particular medical wards and smaller lumen size, were associated with PVC documentation that included insertion site, hand side and lumen size.
Development of terms is needed to assure standardisation of postinsertion PVC documentation. Education of nurses on proper PVC documentation should be given priority.
本研究旨在探讨患者病历中周围静脉导管（PVC）置入后记录的情况，包括用于解释PVC置入部位的描述以及PVC记录的决定因素。
病历记录是安全处理患者PVC的重要前提。然而，此前尚未研究过与PVC记录相关的因素以及病历中如何描述置入部位。
这是一项横断面描述性研究。
从一家大学医院和两家综合医院的内科和外科病房招募了933例置入PVC的成年住院患者（女性占45.7%）。使用数据收集表记录PVC的置入部位、手部、管腔大小、患者年龄和性别。转录病历中的PVC记录。使用逻辑回归分析与记录相关的因素。
在患者病历中确定了10种用于解释PVC置入部位的描述。71.8%的观察到的PVC有任何类型的记录，46.2%的记录包含置入部位、手部和管腔大小。多因素逻辑回归显示，PVC记录与综合医院的内科病房相关（比值比4.59；95%置信区间3.10 - 6.81；p < 0.0001）以及较小的管腔大小（22号）相关（比值比1.81；95%置信区间1.19 - 2.84，p = 0.006）。
病历中PVC记录的程度较低，且用于解释PVC置入部位的描述差异明显。综合医院，尤其是内科病房和较小的管腔大小，与包含置入部位、手部和管腔大小的PVC记录相关。
需要制定术语以确保PVC置入后记录的标准化。应优先对护士进行正确的PVC记录教育。
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