Dokumentation av smärta
En studie baserad på journalgranskning
AbstractThe aim of this study was to examine to what extent documentation of pain assessment with Visual Analogue Scale (VAS) on patients with pain problems was carried out. The study also explored how the documentation followed the existing guidelines of pain. The material was analyzed with descriptive statistics and a qualitative content analysis. The results shows that 43,24 % of total 37 analyzed patient records contained documentation of pain with VAS on the day of hospitalization. All studied journals contained documentation of pain. 37 patient records were followed up during a three day period after pain-consultation at the ward. The results of VAS assessment at the ward day A was 27 %, day B: 24,3 % and day C: 13,5 %. The results of other documented pain problems at the wards were day A: 62,2 %, day B: 56,8 % and day C: 43,2 %. The study shows that there is a shortage in documentation and that the guidelines of the hospital are not followed.