- 期刊
提升安寧病房疼痛評估記錄之完整性
The Improvement of Enhancing The Completeness of Pain Assessment Record in a Hospice Ward
摘要
正確的疼痛評估可使病患的疼痛問題有效被處理，評估結果若能完整記載於病歷中，則可成為醫療團隊間溝通病患疼痛問題的重要參考依據。本專案目的旨在提升某安寧病房疼痛評估記錄的完整性。調查期間自90年3月1日至3月31日，採病歷查核方式，調查內容包括初步疼痛評估記錄的完整性及持續疼痛評估記錄的完整性。調查結果發現疼痛評估記錄的完整性偏低，經分析確立主要問題為缺乏一套疼痛評估記錄的標準、疼痛評估記錄與護理記錄記載內容重複性過高、評估時機在臨床實務執行上不易落實、評估單中屬開放性問題較困難以文字敘述、部分評估內容的用詞病患不會回答。經由制定疼痛評估記錄標準、修訂疼痛評估時機、舉辦教育訓練及規劃一套完善的監測計劃等改善辦法，發現護理人員執行初步疼痛評估記錄完整性由91.3%提升至97.1%及持續疼痛評估記錄完整性由55.3%提升至95.2%，較專案改善前提高。本專案結果建立一套完善的疼痛評估記錄標準，及達到持續性品質改善的目的。
並列摘要
Pain assessment provides important information for doctors and nurses to manage patients’ pain. The complete pain assessment is an essential part of medical record in pain management. The purposes of this article was to promote the completeness of pain assessment in a hospice ward. Form March 1 to March 31, 2001, the completeness of initial pain assessment record and follow-up pain assessment record were studied through chart review. The result showed that pain assessment records were incomplete. There were five main reasons as followed. (1) Lack of standardization in pain assessment. (2) Certain items of pain assessment records were overlapping with the nursing record. (3) Difficulty to find the right timing to assess a patient’s pain in practice. (4) Its difficult for native Taiwanese speakers to find appropriate words to describe their pain sensation. (5) Some questions were not phrased in a simple way for patients to answer. By way of establishing pain assessment standard, enhancement of exact timing of pain assessment, education and training, and establishment of monitoring system, is was found that the completeness of initial pain assessment records was promoted from 91.3% to 97.1%. The completeness of follow-up pain assessment records was promoted from 55.3% to 95.2%. It was a great improvement compared with the time before the intervention. Therefore, this article fulfilled the goal of establishing a set of completed pain assessment record standard, and improving quality of pain management.
延伸閱讀
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