跌倒风险管理的完整性记录：一项横断面研究。
Completeness Documentation of Fall Risk Management: A Cross-Sectional Study.
作者信息
Sugianto Kartika Mawar Sari, Hariyati Rr Tutik Sri, Galleryzki Annisa Rahmi, Koten Elisabet Herlyani Bota, Sudjiati Endang, Bardah Dadan
机构信息
Nursing Master Program, Faculty of Nursing Universitas Indonesia, Indonesia.
Inpatient Department, Ciawi Public Hospital, Indonesia.
出版信息
Iran J Nurs Midwifery Res. 2022 Nov 18;27(6):517-521. doi: 10.4103/ijnmr.ijnmr_109_21. eCollection 2022 Nov-Dec.
BACKGROUND
Patient safety management includes the documentation of fall risks. This study aims to portray the nurses' performance toward the risk of falling management in hospitals.
MATERIALS AND METHODS
A cross-sectional approach was used as the study design to measure the documentation completeness of the nursing process toward the risk of falling at hospitals during 2020. There are 110 selected medical records of hospitalized patients based on inclusion criteria such as low-risk medical records, hospitalization within 3 days, and a maximum hospitalization length of one year after the beginning of the data collection procedure. Univariate analysis is chosen to analyze the data.
RESULTS
The results showed that nurses were inconsistent in implementing fall risk management. Furthermore, the assessment was 68.18%, where 45.45% of nurses made the nursing diagnosis, 4.55% described the problems and etiology, and also 32.72% evaluated patients' integrated records.
CONCLUSIONS
The incomplete documentation of fall risk describes the nonoptimal risk management implementation. The head nurse should develop a dynamic interaction with the fall risk patients, as well as increase nursing coordination and integration.
背景
患者安全管理包括跌倒风险的记录。本研究旨在描述护士在医院跌倒风险管理方面的表现。
材料与方法
采用横断面研究方法作为研究设计，以衡量2020年医院护理过程中跌倒风险记录的完整性。根据纳入标准选择了110份住院患者的病历，如低风险病历、入院3天内以及数据收集程序开始后最长住院时间为一年。选择单因素分析来分析数据。
结果
结果显示，护士在实施跌倒风险管理方面不一致。此外，评估率为68.18%，其中45.45%的护士做出了护理诊断，4.55%描述了问题和病因，32.72%评估了患者的综合记录。
结论
跌倒风险记录不完整描述了风险管理实施不理想。护士长应与跌倒风险患者建立动态互动，同时加强护理协调与整合。
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