Johansson Linda, Wijk Helle, Christensson Lennart
School of Health and Welfare, Institute of Gerontology and Department of Nursing (Dr Johansson), and School of Health and Welfare, Department of Nursing (Dr Christensson), Jönköping University, Jönköping, Sweden; and Sahlgrenska Academy, Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden (Dr Wijk).
Qual Manag Health Care. 2017 Jan/Mar;26(1):15-21. doi: 10.1097/QMH.0000000000000116.
To describe health care staff members' usage and documentation in a Swedish quality registry focusing on a preventive care process regarding the risk area of malnutrition among persons with dementia. The preventive care process includes risk assessment, analysis of underlying causes, planning and performing interventions, as well as evaluating effects.
Data were collected from 2 Swedish quality registries, Senior Alert and the Swedish Dementia Register (Svedem). In total, 1929 people with dementia were assessed and 1432 registered as being at risk of malnutrition or malnourished.
Performed nutritional interventions were registered in approximately 65% of cases. In more than 80% of registrations, the analyses of underlying causes were missing. Those who had registered underlying causes had significantly more interventions and the evaluation of the performed intervention was registered. The time between assessment and evaluation depended on care setting and ranged from 0 to 702 days.
Limitations in registration were noted; however, the register allows staff to focus on nutritional care and has resulted in many risk assessments. Rarely people were registered in all steps of the preventive care process. Large variances in when the performed interventions were evaluated makes it difficult to measure improvements.
描述瑞典一个质量登记系统中医护人员对痴呆症患者营养不良风险领域预防性护理过程的使用和记录情况。预防性护理过程包括风险评估、根本原因分析、干预措施的规划与实施以及效果评估。
数据收集自瑞典的两个质量登记系统,即“高级警报”和瑞典痴呆症登记系统(Svedem)。总共对1929名痴呆症患者进行了评估,其中1432人被登记为有营养不良风险或已营养不良。
约65%的病例记录了所实施的营养干预措施。超过80%的记录中缺少根本原因分析。记录了根本原因的患者接受的干预措施明显更多,且对所实施干预措施的评估也有记录。评估与评估之间的时间取决于护理环境,范围从0到702天。
注意到登记方面存在局限性;然而,该登记系统使工作人员能够专注于营养护理,并已促成了许多风险评估。很少有人在预防性护理过程的所有步骤中都有记录。所实施干预措施的评估时间差异很大,这使得难以衡量改善情况。