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Dannäs, Lotta; Krylén, Ida (2011)
Publisher: Uppsala universitet, Institutionen för folkhälso- och vårdvetenskap
Languages: Swedish
Types: Bachelor thesis
Subjects: Fall prevention, risk factors, geriatric care, documentation, Fallprevention, riskfaktorer, geriatrisk vård, dokumentation
Purpose The purpose of this study has been to investigate the documentation process following the guiding principles of the Quality Norms for Fall Prevention concerning fall risk assessment, risk identification, fall preventive measures, information and the making of an individual care plan. Method This study is a quantitative, descriptive and retrospective journal review study. There were 100 journals examine the existing documentation concerning fall risk assessment of patients who received treatment in geriatric patient care. The sample was consecutively. Results The results showed that fall risk assessment was documented in 79 of 100 examined journals. 56 (71 %) of the fall risk assessments were made within 24 hours. In 59 of 100 journals the patient, relatives or former caretakers was asked whether the patient had had a fall within the last year, and in 61 of 100 journals it was documented that the nursing staff had made an assessment that the patient was going to have a fall during his or her length of stay if no preventive measures were set in. The majority of fall risk factors and fall preventive measures were documented within the areas of walking and transfer. It was documented that the patient was informed of fall risk, fall risk factors and fall preventive measures in 15 of 100 journals. For 33 of 68 (49 %) patients with an identified increased fall risk, a care plan was established.  Conclusion Quality norm is recently introduced and enforced in the relative extent. Since the objective is to appropriate risk assessment should be performed on all enrolled patients in geriatric patient care, so it should be performed and documented in all patients. Syfte Syftet med studien var att undersöka hur dokumentationen utförs utifrån riktlinjerna i kvalitetsnormen för fallprevention gällande fallriskbedömning, riskidentifiering, fallpreventiva åtgärder, information och upprättande av en individuell vårdplan. Metod Studien var en kvantitativ, deskriptiv och retrospektiv journalgranskningsstudie. Det var 100 journaler som granskades gällande dokumentation angående fallriskbedömning av patienter som vårdats inom geriatrisk sluten vård. Urvalet var konsekutivt. Resultat Resultatet visade att i 79 av 100 granskade journaler var fallriskbedömning dokumenterad. Det var 56 (71 %) fallriskbedömningar som var utförda inom 24 timmar. I 59 av 100 journaler har patienten, anhöriga eller tidigare vårdgivare tillfrågats om patienten fallit senaste året och i 61 av 100 journaler fanns det dokumenterat att vårdpersonalen gjort en bedömning om patienten kommer falla under vårdtiden om inga förebyggande åtgärder sätts in. Flest fallriskfaktorer och fallpreventiva åtgärder inom området gång och förflyttning dokumenterades. Det fanns dokumenterat att patienten blev informerad angående fallrisk, fallriskfaktorer och fallpreventiva åtgärder i 15 av 100 journaler. För 33 av 68 (49 %) patienter med en bedömd förhöjd fallrisk upprättades en vårdplan. Slutsats Kvalitetsnormen är nyligen införd och efterlevs i relativ stor utsträckning. Eftersom målet är att fallriskbedömning ska utföras på samtliga inskrivna patienter inom geriatrisk sluten vård så bör den utföras och dokumenteras på samtliga patienter.
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