Departmental Bulletin Paper 大学教員の継続的な介入支援によるA 病院の看護記録の変化

神島, 滋子  ,  中村, 惠子

本研究の目的は看護教員が行った臨床への看護記録の継続介入支援の成果について介入前後の比較を通して明らかにすることである.研究方法はA 病院の5 つの病棟においてランダムに患者1 名につき該当する月の1 週間の記録と看護計画,アセスメントについて介入前と介入後の記録を調査対象とした.分析はそれぞれの項目が記録されているか否かの記入率について介入前後で比較した.倫理的配慮として札幌市立大学倫理委員会の承認を得た.分析の対象患者数は介入前50 名,介入後50 名分の記録であった.記載のあった看護計画は介入前70 件,介入後64 件であった.看護計画のデータベース上の修正のないものは介入前92% であり,介入後は認めなかった.その他データベースの記入率,看護計画の記入率,SOAPの各項目の記入率を比較したところ,多くの項目で介入後に記入率が上昇した.データベースはアセスメントのうち早期に患者の全体を把握するためのツールであるが,今回の結果ではすべてのアセスメントフレームで記入率が上昇した.看護計画では「項目」「情報」など疾病の特性や問題の原因となる項目の記入率が増加していた.さらに,SOAP では情報をアセスメントして実践にうつすためのプランが増加しており,それぞれの看護実践における患者の十分なアセスメントと判断した上での実践が行われるようになったことが示唆された.
The purpose of this study was to reveal, through a before-after comparison, the outcomes of ongoing intervention support of nursing records by clinical nursing teachers. Research methods were based on the random survey of records and nursing care plans for one week records of the relevant month per patient, which were assessed pre- and post-intervention in five wards in Hospital A. Our analysis compared the fill rate for each item before and after intervention. Approval was received from the Sapporo City University Ethics Committee. The target number of patient records used for the analysis was 50 before the intervention and 50 after the intervention, and 70 nursing care plans were reviewed before the intervention and 64 after the intervention. We found that 92% of nursing care plans were without modification pre-intervention, while no modified plans were observed after the intervention. The completion rate for other data and the fill rate for the nursing care plan were compared for each SOAP item, with the fill rate after the intervention increased for a number of items. The database is a tool for gaining a quick understanding of the patient’s need during assessment, and the results showed that the fill rate rose for the entire assessment framework. Fill rate scores items on the nursing care plan related to illness characteristics and causes of problem increased. Furthermore, the assessment information in the SOAP and planning to put it into practice increased, and it suggests that adequate assessment and judgments regarding patients were carried out and put into practice for each nursing competence.

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