农村地区医疗中心临床护理人员对患者体重的记录

Pub Date : 2023-01-01 DOI:10.1097/TIN.0000000000000303
Helen Ballew, Robin Jean Maroulakis, P. B. Moore
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引用次数: 0

摘要

在特定时期内体重减轻是识别住院患者营养不良的重要指标。在电子病历中记录准确的体重对于识别和治疗营养不良至关重要。该项目的目的是评估临床护理人员对记录患者体重的依从性。在5周的时间内,随机选择7天(n = 122)进行医疗记录审查。记录体重文件和获得体重的方法。91.2%的时间记录了体重信息。客观方法获得患者体重的比例为77.9%,主观方法获得患者体重的比例为13.9%。结果表明,有必要教育临床护理人员记录患者体重作为营养状况指标的重要性,以改善营养不良和高危患者的预后。
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Documentation of Patient Weights by Clinical Care Staff in a Rural, Regional Medical Center
Weight loss over a specific time period is an important indicator for recognizing malnutrition in hospitalized patients. Documenting accurate weights in the electronic medical record is crucial to identify and treat malnutrition. The purpose of this project was to evaluate clinical care staff compliance with documenting patient weight. A medical record review was performed on 7 randomly selected days (n = 122) over a 5-week period. Documented weight and method of obtaining weight were recorded. Weight information was documented 91.2% of the time. Objective methods of obtaining patient weight were used 77.9% of the time, while subjective methods were used 13.9% of the time. Results support the need to educate the clinical care staff on the importance of documenting patient weights as an indicator of nutritional status in order to improve outcomes in malnourished and at-risk patients.
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