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박인숙 ( Park Ihn-Sook ) - 서울대학교병원
장미 ( Jang Mi ) - 서울대학교병원 수간호사
유순애 ( Rew Soon-Ae ) - 서울대학교병원 수간호사
김희진 ( Kim Hee-Jin ) - 서울대학교병원
오필주 ( Oh Pil-Ju ) - 서울대학교병원
정희정 ( Jung Hee-Jung ) - 서울대학교병원
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Abstract
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Purpose: This study was done to analyse nursing records to identify the nature of pain and actual conditions of pain management in patients hospitalized in one university hospital.
Methods: The participants in this study were 783 patients with a length of stay of 3 to 30 days who were discharged from medical wards between June 1 and June 30, 2009. Data on nursing records related to pain management from these patients were reviewed using the Electronic Nursing Records (ENRs) system.
Results: Over 30 percent of 10,702 nursing records related to pain assessment had no record on region, severity, nature or frequency of pain. About 30 percent of 13,638 nursing records related to pain intervention showed non-drug pain management techniques.
Conclusion: Accurate and complete records on pain assessment including region, severity, nature and frequency of pain are essential to effectively manage patients’ pain. Improvement in ENRs system for better assessment and management of pain is required as well as education programs on a standardized measuring tool for both nurses and patients.
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KeyWords
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통증, 통증간호, 전자의무기록
Pain, Pain nursing, Electronic nursing record
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원문 및 링크아웃 정보
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등재저널 정보
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