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首页> 外文期刊>The American journal of hospice and palliative care >Documentation in palliative care: nursing documentation in a palliative care unit--a pilot study.
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Documentation in palliative care: nursing documentation in a palliative care unit--a pilot study.

机译：姑息治疗文献：姑息治疗部门的护理文献-一项初步研究。

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摘要

Palliative care seeks to enhance quality of life in the face of death by addressing the physical, psychological, social, and spiritual needs of patients with advanced disease. The purpose of this paper is to explore whether palliative patients' needs, nursing actions, and evaluation can be identified in the nursing documentation. Data consisted of reviews of patients' case records in a palliative care unit. Data were analyzed using content analysis and counting frequency of keywords used from the Well-being Integrity Prevention and Safety (VIPS) model, followed by an inductive analysis of the case record documentation aiming to identify palliative care components. The result shows that the documentation revealed physical care, especially pain, more frequently than other needs. Nursing documentation focuses on identification more than on nursing actions and evaluation.
机译：姑息治疗旨在通过解决晚期疾病患者的身体，心理，社会和精神需求来提高面对死亡时的生活质量。本文的目的是探讨能否在护理文档中确定姑息患者的需求，护理措施和评估。数据包括对姑息治疗病房中患者病历的回顾。使用内容分析对数据进行分析，并对从“福祉完整性预防与安全（VIPS）”模型中使用的关键字进行计数，然后对案例记录文档进行归纳分析，以识别姑息治疗的组成部分。结果表明，与其他需求相比，文档更频繁地揭示了身体护理，尤其是疼痛。护理文档更着重于识别，而不是护理措施和评估。

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