Abstracting pain management documentation from the electronic medical record: comparison of three hospitals

作者：Samuels Joanne G^*

来源：Applied Nursing Research, 2012, 25(2): 89-94.

DOI：10.1016/j.apnr.2010.05.001

Background: Pain management science results are derived from research conducted using medical record. %26lt;br%26gt;Approach: This article describes methodological issues arising from abstracting pain management documentation (PMD) from the electronic medical record in three hospitals. After approval, PMD data were collected from the patient%26apos;s history and physical, discharge summary, operative care notes, computerized nursing flow sheets, progress notes, and medication records. %26lt;br%26gt;Results: Each acute care facility required a different approach to abstract data. Inconsistent documentation in pain management assessments, interventions, and reassessments were identified across hospitals. %26lt;br%26gt;Discussion: Inconsistencies pose measurement threats and hinder benchmarking efforts. Work to standardize PMD across propriety computer systems is warranted.

• 出版日期2012-5