进行护理审计,以衡量Jayanagar Sagar医院的护理专业人员在其住院期间对患者和家庭进行的护理专业教育领域的文件遵守情况

M. Varghese, G. RekhaS
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摘要

护理文件是由合格的护士或其他护理人员在专业护士的指导下计划并交付给个人客户的医疗护理记录。它包含与护理过程的步骤相一致的信息。这是护士日常工作中不可缺少的一部分。细致的护理文件是病人护理的重要组成部分。提供优质的护理,从而有效地谈论病人护理的能力取决于所有或任何卫生保健专业人员可获得的数据标准。这些信息的一个重要部分是医疗护理计划中的护理文件。本研究的目的:在班加罗尔Sagar医院使用护理审计来评估患者教育过程文件的有效性。材料与方法:采用简单的系统抽样法选取病例记录,并采用结构化的核对表对每份档案进行分析。整个数据被合并为整个excel表格的一个结果。在2018年11月1日至2019年10月31日(12个月)期间,采用结构化检查表对病例记录中的并发患者教育表进行分析。采用简单的系统抽样技术选取护理档案,约50%的入院患者被纳入研究,4317例(53.38%)被纳入研究。结果:完全依从3726例(86.30%),部分依从399例(9.24%),不依从192例(4.44%)。最符合文件要求的是安全育儿做法、免疫接种和特定疾病信息(99.30%)。最小的合规性出现在疼痛管理和文档中443(部分和不合规性占11.07%)。数据还显示疾病特定信息的依从性为99%,药物管理的依从性为99%,手卫生的依从性为91%,疼痛评估的依从性为81%,跌倒预防的依从性为62%,压疮预防的依从性为12%,免疫接种的依从性为9%。结论:采用标准
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Nursing audit conducted to gauge the documentation compliance by nursing professionals at Sagar hospital, Jayanagar within the domain of patient and family education rendered by nursing professionals during the course of their hospita
Nursing documentation is that the record of medical care that's planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a professional nurse. It contains information in accordance with the steps of the nursing process. It constitutes an integral a part of the nurse’s daily work. Meticulous nursing documentation is a crucial a part of patient care. The delivery of excellent care and therefore the ability to speak effectively about patient care depends on the standard of data available to all or any health care professionals. One important a part of this information is nursing documentation in medical care plans. Aim of the Study: to gauge the effectiveness of documentation of Patient education process using Nursing audit at Sagar Hospital, Bangalore. Materials and Methods: The case records were chosen by simple systematic sampling method and every file was analysed employing a structured check list. the whole data were combined into one result for the whole excel sheet. Concurrent patient education form review within the case record were analysed employing a Structured checklist during 1st Nov 2018 to 31st OCT 2019 (12months). Care file were selected employing a simple Systemic Sampling Technique and about 50% of admissions were included within the study and 4317(53.38%) of the entire admission. Results: Totally compliant were 3726 (86.30%), partially compliant were 399 (9.24%) and non-compliant were 192 (4.44%). the very best compliance of documentation was seen in safe parenting practices, immunization and disease specific information (99.30%). the smallest amount compliance was seen in pain management and documentation 443 (partially and non-compliant category constitutes 11.07%. Data also revealed compliance with disease specific information 99%, medication management 99%, hand hygiene was 91%, pain assessment 81%, fall prevention 62%, pressure ulcer prevention 12%, Immunization 9%. Conclusion: Use a standa
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