Keeping record of the postoperative nursing care of patients
Roets, Liseth; Aucamp, M.C.; De Beer, H.; Niemand, M.
The aim of this research project was to evaluate the recordkeeping
of postoperative nursing care. A total of 186 randomly
selected patient records were evaluated in terms of
a checklist that included the most important parameters
for postoperative nursing care. All the patients underwent
operations under general anaesthetic in one month in a
Level 3 hospital and were transferred to general wards
after the operations.
The data collected was analysed by means of frequencies.
One finding was that the neurological status of most patients
was assessed but that little attention was paid in the
patient records to emotional status and physical comfort.
The respiratory and circulatory status of the patients and
their fluid balance were inadequately recorded. The patients
were well monitored for signs of external haemorrhage,
but in most cases haemorrhage was checked only
once, on return from the theatre. Although the patients’
pain experience were well-monitored, follow-up actions
after the administration of pharmacological agents was
poor. The surgical intervention was fully described and,
generally speaking, the records were complete and legible,
but the signatures and ranks of the nurses were illegible.
Allergies were indicated in the most important
records.
The researchers recommend that a comprehensive and
easily usable documentation form be used in postoperative
nursing care. Such a form would serve as a checklist
and could ensure to a large degree that attention is given
to the most important postoperative parameters. Errors
and negligence could also be reduced by this means
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