The accuracy of patient records in Swedish nursing homes: congruence of record content and nurses' and patients' descriptions
The accuracy of patient records in Swedish nursing homes: congruence of record content and nurses' and patients' descriptions
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DOI：
10.1046/j.1471-6712.2001.00044.x
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发表时间：
2001-01-01
影响因子：
1.9
通讯作者：
Ehnfors, M
中科院分区：
文献类型：
--
作者：
Ehrenberg, A;Ehnfors, M
来自患者记录的数据将越来越多地用于护理规划、质量评估、研究、健康规划和资源分配。然而，关于这些辅助数据的准确性的知识是有限的，只有少数研究已经进行了护理记录的准确性。本研究旨在分析护理之家的护理文件与护患双方的一些具体问题描述之间的一致性。比较病房护士接受过培训的结构化记录的基础上做护理过程（研究组）和病房没有干预发生（参考组）。从随机选择的疗养院居民（n = 85）的病历中收集数据。所使用的方法是审计病人的记录和结构化的访谈居民和护士。当将患者记录与护士和居民的报告进行比较时，该研究显示患者记录的准确性存在相当大的缺陷。从护士和病人的记录访谈数据之间的整体协议是低的。研究组的一致性优于参照组，参照组记录的数据仅按时间顺序排列。该研究明确表明，使用记录作为评估、规划和发展护理的数据来源存在重大局限性。
Data from patient records will increasingly be used for care planning, quality assessment, research, health planning and allocation of resources. Knowledge about the accuracy of such secondary data, however, is limited and only a few studies have been conducted on the accuracy of nursing recording. The aim of this study was to analyse the concordance between the nursing documentation in nursing homes and descriptions of some specific problems of nurses and patients. Comparisons were made between wards where nurses had received training in structured recording based do the nursing process (study group) and wards where no intervention had taken place (reference group). Data were collected from the patient records of randomly selected nursing home residents (n = 85). The methods used were audits of patient records and structured interviews with residents and nurses. The study revealed considerable deficiencies in the accuracy of the patient records when the records were compared with the reports from nurses and residents. The overall agreement between the interview data from nurses and from the patient records was low. Concordance was better in the study group as compared with the reference group in which the recorded data were structured only following chronological order. The study unequivocally demonstrates that there are major limitations in using records as a data source for the evaluation, planning and development of care.