在临床调整疼痛评估 (CAPA) 工具文档中探索内部变化
Sandra Hagstrom1, Susan O'Conner-Von2, Michelle A Mathiason2
1M Health Fairview, Minneapolis, MN.
概括
护士在记录临床对准疼痛评估 (CAPA) 工具时显示出显著的差异. 疼痛评估文档中的这种不一致性妨碍了有效的患者护理和治疗监测.
科学领域:
- 护理 护理 护理
- 疼痛管理 疼痛管理
- 医疗信息学 医疗信息学
背景情况:
- 临床对齐的疼痛评估 (CAPA) 工具旨在改善患者和临床医生的关于疼痛的沟通,而不仅仅是简单的强度评级.
- 在CAPA的管理和文档的变化可能会阻碍其在临床实践中的有效性.
研究的目的:
- 描述护士如何记录他们使用CAPA工具的变化.
- 为了识别护士在CAPA文档中存在不一致的模式.
主要方法:
- 一项描述性研究分析了103名护士和1,123名成人医疗和中介护理单位的患者的电子健康记录.
- 使用描述和推断统计数据来比较各单位和个体护士之间的记录实践.
主要成果:
- 在护士中观察到CAPA领域文档的频率和时间的显著变化,范围从0%到100%.
- 不一致的文档包括睡眠患者的图表和CAPA领域内的各种选择选择.
- 在同一单位的个体护士中持续存在变化,这表明问题超出了单位特定因素.
结论:
- 护士不一致的CAPA文档损害了追踪疼痛趋势和评估治疗疗效的能力.
- 观察到的变异性表明CAPA工具本身的潜在含糊性,而不是仅仅基于单位的做法.
- 标准化CAPA文档对于实现其在综合性疼痛评估和管理中的全部潜力至关重要.
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