摘要
目的归纳和分析癌症疼痛护理文件书写中存在的问题并提出相应对策,以期提高疼痛护理文件书写的质量。方法采用便利抽样法,选取2019年7-9月北京大学肿瘤医院内科出院的150份恶性肿瘤伴慢性癌痛患者的终末病历,应用"癌症疼痛护理记录质量评价标准"对疼痛相关护理文件的书写质量进行评价。采用百分数表示不同得分的病历比例以及各条目书写的正确率。结果癌痛护理文件书写质量评价满分的病历占8.67%(13/150),90~99分占34%(51/150),80~89分占36%(54/150),70~79分占14.67%(22/150),<70分占6.67%(10/150)。癌痛护理文件书写正确率较低的条目依次是入院患者进行全面疼痛评估(32%,48/150)、药物不良反应预防及观察的护理指导(70%,105/150)、疼痛控制平稳(NRS≤3分)的患者至少每2周进行1次全面疼痛评估(72%,108/150)。结论癌痛护理文件书写的质量可反映疼痛护理工作的落实情况及护理质量,目前临床癌痛护理文件中仍存在较多问题,提示管理者应在制度完善、护士培训、质量督导及信息支持等方面采取有针对性的措施以提高癌痛护理文件书写的质量,促进护士在癌痛全程管理中更好地发挥专业作用。
Objective To summarize and analyze the problems existing in the writing of cancer pain nursing documents and propose corresponding measures so as to improve the writing quality of pain nursing document.Methods From July to September 2019,convenience sampling was used to select 150 terminal medical records of patients with chronic cancer pain discharged from the Department of Internal Medicine of Peking University Cancer Hospital.The"Quality Evaluation Criteria of Cancer Pain Nursing Record"was applied to evaluate the writing quality of pain-related nursing documents.Percentages were used to indicate the proportion of medical records with different scores and the correct rate of each entry.Results Among cancer pain nursing document writing quality evaluation scores,medical records with full score accounted for 8.67%(13/150),90-99 points accounted for 34%(51/150),80-89 points accounted for 36%(54/150),70-79 points accounted for 14.67%(22/150),less than 70 points accounted for 6.67%(10/150).The items with a low rate of correctness of the cancer pain nursing documents included that the comprehensive pain assessment for admitted patients(32%,48/150),nursing guidance on prevention and observation of adverse drug reactions(70%,105/150),patients with stable pain control(NRS≤3 points)underwent a comprehensive pain assessment at least every two weeks(72%,108/150).Conclusions The quality of cancer pain nursing documents can reflect the implementation of pain nursing work and the quality of care.At present,there are still many problems in clinical cancer pain nursing documents.It is reminded that managers should take targeted measures in terms of system improvement,nurse training,quality supervision and information support to improve the writing quality of cancer pain nursing document,and promote nurses to play a professional role in the overall management of cancer pain.
作者
金淼
杨红
陆宇晗
于文华
张红
Jin Miao;Yang Hong;Lu Yuhan;Yu Wenhua;Zhang Hong(Nursing Department,Peking University Cancer Hospital&Beijing Institute for Cancer Research,Beijing 100142,China)
出处
《中华现代护理杂志》
2020年第32期4507-4510,共4页
Chinese Journal of Modern Nursing
基金
北京市属医院科研培育计划(PX2017052)。
关键词
癌症疼痛
护理文件书写
问题
对策
Cancer pain
Nursing document writing
Problems
Measures
