Documentation of Pain Management with TT- 2000+ in May 2008 Viewed from Clinical Nursing Practice

摘要

Background: Electronic Patient Record (EPR) TT- 2000+ was implemented in Hospital Orton in January 2008. The software TT 2000+ was implemented in 2005. TT- 2000+ enables structured and specifically defined documentation in clinical nursing practice. Objectives: To describe the use of pain management documentation into TT- 2000+ and how the results can be implemented into clinical nursing practice. Can the results be used in development of clinical nursing practice? How does the evaluation of pain reflect into the number of documentation? Methods: The data were obtained from documentations made in May 2008 from patient groups that had undergone total hip arthroplasty and total knee arthroplasty. Results: The number of total hip arthroplasty patients was 60 and total knee arthroplasty patients 51. The total number of pain documentations with the group of THA's was 992 and with TKA's 913. Discussion: Due to the circumstances in May 2008, the numbers of documentation into the TT- 2000+ are inadequate. Therefore, the documentation needs further research within a longer period of time. Undefined and unified way of maintaining and recording should be considered in processing information in clinical practice.