提升病人疼痛評估記錄完整率

Strategies to increase the completeness rate of patient pain assessment records

疼痛病人應給予完整評估並記錄，當未獲得改善時應持續追蹤記錄疼痛的變化，護理人員對疼痛評估記錄是否完整，是影響疼痛處置的重要因素。採回溯性病歷調查單位2015 年9 月15 日至30 日共176 位病人，疼痛評估記錄完整率為75.4%。原因為：一、對疼痛評估修正規範內容不熟悉。二、缺乏明確的疼痛護理記錄標準。三、電腦資訊系統不夠人性化。四、缺乏監測計畫。舉辦在職人員疼痛評估記錄相關教育課程、規劃病人疼痛記錄查核、修訂「疼痛評估紀錄資訊系統」、建置電腦資訊設置提醒功能、建置資訊系統自動帶入疼痛記錄。疼痛評估記錄完整率提升至為97.7%|護理師對資訊化疼痛評估記錄的滿意度提升至9.2 分，達專案目的，可作為類似單位參考。

A complete assessment and record of patients’ pain is essential. In case of persistent pain, thechange in pain should be recorded continually. Pain treatment is determined through a completepain assessment record prepared by a nurse. For 176 patients under retroactive medical recordsurvey from September 15 to 30, 2015, the completeness rate of pain assessment record was75.4%. The reasons for incompleteness of the assessment records were the lack of familiarity withthe revised regulations for pain assessment, lack of definite pain nursing record standards, non–user-friendly computer information system, and lack of a monitoring plan. The pain assessmentrecord-related education for health care personnel, planning for pain record check, a revised“Pain Assessment Record Information System,” an established computer information devicealert function, and an established automatic pain record import into the information system weremanaged. At present, the “Pain Assessment Record Information System” is online. Moreover, therevised pain nursing regulations includes the information system and operational steps for use inthe hospital. The “Pain assessment record completeness checklist” was included in the qualitymonitoring items. Between July 2016 and December 2018, the “patient pain assessment recordcompleteness rate” was maintained at 98% on an average, and the average “satisfaction to the PainAssessment Record Information System” reached 9 points. Overall, the project goal was achieved,which suggests that the system could be used as a reference for similar units.