| Identifying Minimum Data Sets of Oral Mucous Integrity Assessment for Documentation Systematization |
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Myoung Soo Kim, Hyun Kyeong Jung, Myung Ja Kang, Nam Jung Park, Hyun Hee Kim, Jeong Mi Ryu |
1Professor, Department of Nursing, Pukyong National University, Korea.
2Unit Manager, Pusan National University Hospital, Korea. hyunk-jung@hanmail.net
3Team Manager, Pusan National University Hospital, Korea.
4Doctoral Candidate, Department of Nursing, Pukyong National University, Korea. |
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Received: 4 October 2018 • Revised: 27 December 2018 • Accepted: 7 January 2019 |
| Abstract |
PURPOSE
The purpose of this study was to identify minimum data sets for oral mucous integrity-related documentation and to analyze nursing records for oral care.
METHODS
To identify minimum data sets for oral status, the authors reviewed 26 assessment tools and a practical guideline for oral care. The content validity of the minimum data sets was assessed by three nurse specialists. To map the minimum data sets to nursing records, the authors examined 107 nursing records derived from 44 patients who received chemotherapy or hematopoietic stem cell transplantation in one tertiary hospital.
RESULTS
The minimum data sets were 10 elements such as location, mucositis grade, pain, hygiene, dysphagia, exudate, inflammation, difficulty speaking, and moisture. Inflammation contained two value sets: type and color. Mucositis grade, pain, dysphagia and inflammation were recorded well, accounting for a complete mapping rate of 100%. Hygiene (100%) was incompletely mapped, and there were no records for exudate (83.2%), difficulty speaking (99.1%), or moisture (88.8%).
CONCLUSION
This study found that nursing records on oral mucous integrity were not sufficient and could be improved by adopting minimum data sets as identified in this study. |
| Key Words:
Oral health, Oral ulcer, Oral hygiene, Nursing records |
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