School of Business, Western Sydney University, Locked Bag 1797, Penrith South, NSW, 2751, Australia.
Illawarra Shoalhaven Local Health District, PO Box 239, Port Kembla, NSW, 2505, Australia.
BMC Palliat Care. 2023 Oct 21;22(1):157. doi: 10.1186/s12904-023-01279-1.
Evidence-based palliative care requires comprehensive assessment and documentation. However, palliative care is not always systemically documented - this can have implications for team communication and patient wellbeing. The aim of this project was to determine the effectiveness of an aide-mémoire - POMSNAME - to prompt the comprehensive assessment of the following domains by clinicians: pain, orientation and oral health, mobility, social situation, nausea and vomiting, appetite, medication, and elimination.
A placard depicting the aide-mémoire was distributed to community-based nurses who received training and support. The case notes of palliative care patients were evaluated one month before the intervention, and was repeated at one month, eight months, and fifty months following the intervention. The 235 case notes pertained to patients who received palliative care from a team of 13 registered nurses at one community health service.
The documented assessment of palliative care patients improved across all nine domains. The most significant improvements pertained to patients' social situation, orientation, and nausea, eight months after the aide-mémoire was introduced (170.1%, 116.9%, and 105.6%, respectively, all at p < .001). Although oral health and medication assessment declined one-month after the aide-mémoire was introduced (-41.7% and-2.1%, respectively), both subsequently improved, thereafter, at both 8 months and 50 months after the aide-mémoire was introduced.
The improvement of palliative care documentation across all nine domains demonstrates the potential of the POMSNAME aide-mémoire to prompt the comprehensive assessment of patients by clinicians with generalist expertise. Research is required to determine whether other domains warrant inclusion and how.
循证姑息治疗需要全面评估和记录。然而，姑息治疗并不总是系统记录的 - 这可能会对团队沟通和患者的幸福感产生影响。本项目的目的是确定助记符 - POMSNAME - 提示临床医生全面评估以下领域的有效性：疼痛、定向和口腔健康、活动能力、社会状况、恶心和呕吐、食欲、药物和排泄。
向接受培训和支持的社区护士分发了一张描述助记符的挂牌。在干预前一个月评估姑息治疗患者的病历记录，并在干预后一个月、八个月和五十个月重复评估。235 份病历记录涉及到在一个社区卫生服务中心由 13 名注册护士组成的团队接受姑息治疗的患者。
所有九个领域的姑息治疗患者的记录评估都有所改善。引入助记符八个月后，患者的社会状况、定向和恶心评估的改善最为显著（分别为 170.1%、116.9%和 105.6%，均为 p<0.001）。尽管口腔健康和药物评估在引入助记符一个月后下降（分别为-41.7%和-2.1%），但随后在引入助记符八个月和五十个月后均有所改善。
所有九个领域的姑息治疗记录的改善表明，POMSNAME 助记符有可能提示具有普通专家知识的临床医生全面评估患者。需要研究确定其他领域是否需要纳入以及如何纳入。
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