在急诊室通过法医镜头记录伤口
Celia J Filmalter1, Tanita Botha2, Tanya Heyns1
1Department of Nursing Science, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.
International emergency nursing
|September 15, 2023
概括
无论护理水平如何,急诊室的伤口文档都是不够的. 实施严格的护理指南伤口文档对于患者权利和护士保护至关重要.
科学领域:
- 法医护理 在法医护理.
- 紧急医疗 紧急医疗
- 医疗文件 医疗文件
背景情况:
- 准确的伤口文档对于患者的护理和评估至关重要.
- 在急诊室受伤的患者可能被认为是法医患者,需要精心记录证据.
研究的目的:
- 从法医角度检查急诊室的伤口文件.
- 为了比较不同级别的急救部门的伤口记录实践.
主要方法:
- 进行了一项描述性回顾性研究.
- 从三个急诊室的受伤患者的515张纸质医疗档案中随机抽取样本.
- 用结构化数据收集工具和描述性统计数据分析数据.
主要成果:
- 伤口类型和部位在所有档案中都记录 (100%).
- 在98.6%的档案中记录了受伤机制.
- 关于失血 (18.1%),伤口大小 (15%),伤口含量 (1档),伤口形状和周围皮肤状况的信息记录不佳.
结论:
- 在所有级别的护理中,急诊室的伤口文档始终很差.
- 为准确的伤口记录,为急诊室的护士制定严格的指导方针至关重要.
- 适当的文件保护患者的人权,并保护护理专业人员.
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