用临床护理分类系统评估急性冠状动脉综合征患者的护理护理文档的遵守情况:一个描述性和指导性的内容分析研究:紧急部门的临床护理分类系统:描述性和指导性的内容分析研究
Setareh Homami1, Farshad Zinvand-Moghaddam, Maryam Rassouli
1Author Affiliations: Research Center for Public Health Sciences and Technologies, Semnan University of Medical Sciences, Semnan, Iran (Dr Homami); and Department of Public Health, Semnan University of Medical Sciences, Semnan, Iran (Dr Homami); Student Research Committee, Nursing School, Semnan University of Medical Sciences, Semnan, Iran (Mr Zinvand-Moghaddam); Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran (Dr Rassouli); and School of Nursing, College of Health Sciences, University of Nizwa, Nizwa, Sultanate of Oman (Dr Rassouli); Department of Health Information Technology, Khomein University of Medical Sciences, Khomein, Iran (Dr Valinejadi); Health in Emergencies and Disasters Group, Faculty of Allied Medical Sciences, Qom University of Medical Sciences, Qom, Iran (Dr Ebrahimian); and Nursing Care Research Center, Semnan University of Medical Sciences, Semnan, Iran (Dr Ebrahimian).
这项研究使用临床护理分类 (CCC) 系统评估了急性冠状动脉综合征 (ACS) 患者的护理文档. 调查结果显示,合规性很低,这表明需要改善护理文档标准.
科学领域:
- 护理 护理 护理
- 心脏病学 心脏病学
- 医疗信息学 医疗信息学
背景情况:
- 临床护理分类 (CCC) 系统为护理文档提供了一个结构化的方法.
- 有效的护理文档对于优质的患者护理至关重要,特别是对于急性冠状动脉综合征 (ACS) 患者.
研究的目的:
- 评估ACS患者的护理护理文档是否符合CCC系统.
- 在CCC框架内确定当前护理文档实践的优点和弱点.
主要方法:
- 采用定向内容分析,检查了18个月的急诊室的108个ACS患者记录.
- 此外,使用有目的抽样分析了口头护理班次移交报告.
- 提取了意义单位并与CCC心脏组件进行了比较.
主要成果:
- 与CCC心脏组件的整体兼容性低,为27.3%.
- 具体的相容率为护理诊断的25%,护理干预的33.3%和护理干预评估的25%.
- 在分析过程中,出现了新的含义单元,例如患者转诊方法和IV线位点.
结论:
- 对于ACS患者的护理文档显示,对CCC系统的心脏部件的坚持有限.
- 通过更好的CCC系统集成,有很大的潜力提高护理文档的质量和一致性.
- 需要对护理诊断,干预和评估进行有针对性的改进,以符合CCC标准.
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