Department of Nursing, University of New Hampshire, Durham, 03824, USA.
Appl Nurs Res. 2012 May;25(2):89-94. doi: 10.1016/j.apnr.2010.05.001. Epub 2010 Jun 29.
Pain management science results are derived from research conducted using medical record.
This article describes methodological issues arising from abstracting pain management documentation (PMD) from the electronic medical record in three hospitals. After approval, PMD data were collected from the patient's history and physical, discharge summary, operative care notes, computerized nursing flow sheets, progress notes, and medication records.
Each acute care facility required a different approach to abstract data. Inconsistent documentation in pain management assessments, interventions, and reassessments were identified across hospitals.
Inconsistencies pose measurement threats and hinder benchmarking efforts. Work to standardize PMD across propriety computer systems is warranted.
疼痛管理科学的研究结果源自对病历记录进行的研究。
本文描述了从三家医院的电子病历中提取疼痛管理文件（PMD）时出现的方法学问题。经批准后，从患者的病史和体检、出院小结、手术护理记录、计算机化护理流程表、进度记录和用药记录中收集 PMD 数据。
每个急症护理机构都需要采用不同的方法来提取数据。不同医院之间的疼痛管理评估、干预和再评估的记录不一致。
不一致性对测量构成威胁，并阻碍基准测试工作。有必要在专用计算机系统中对 PMD 进行标准化。
