Samuels Joanne G, Kritter Dawn
Department of Nursing, University of New Hampshire, Durham, USA.
Comput Inform Nurs. 2011 Sep;29(9):512-8, quiz 519-20. doi: 10.1097/NCN.0b013e31821a1582.
Pain management documentation, consisting of assessment, interventions, and reassessment, can help provide an important means of communication among practitioners to individualize care. Standard-setting organizations use pain management documentation as a key indicator of quality. Adoption of the electronic medical record alters the presentation of pain management documentation data for clinical and quality evaluation use. The purpose of this study was to describe pain management documentation output from the electronic medical record to gain an understanding of its presentation and evaluate the quantity and quality of the output. After institutional review board approval, data were abstracted from 51 electronic records of postsurgical patients in a 100-bed community hospital. Time-variant pain assessments, interventions, and reassessments were organized into pain management episodes to provide clinically interpretable data for evaluation. Data sources were identified. Data generated 1499 episodes for analysis. Analysis of variance results implied that pain management documentation changes with pain severity. Despite legibility and date and time stamping, inconsistencies and omitted and duplicated documentation were identified. Inconsistent data origination posed difficulty for interpreting clinically relevant associations. Improvements are required to streamline fields and consolidate entries to allow for output in alignment with care.
疼痛管理文档，包括评估、干预措施和重新评估，有助于为从业者之间提供一种重要的沟通方式，以实现个性化护理。标准制定组织将疼痛管理文档用作质量的关键指标。电子病历的采用改变了用于临床和质量评估的疼痛管理文档数据的呈现方式。本研究的目的是描述电子病历中的疼痛管理文档输出，以了解其呈现方式，并评估输出的数量和质量。经机构审查委员会批准后，从一家拥有100张床位的社区医院的51份外科手术患者电子记录中提取数据。随时间变化的疼痛评估、干预措施和重新评估被组织成疼痛管理事件，以提供可用于评估的临床可解释数据。确定了数据来源。生成了1499个事件用于分析。方差分析结果表明，疼痛管理文档随疼痛严重程度而变化。尽管文档清晰可读且有日期和时间标记，但仍发现了不一致以及遗漏和重复的文档。数据来源不一致给解释临床相关关联带来了困难。需要进行改进以简化字段并合并条目，以便输出与护理保持一致。
