J Korean Crit Care Nurs.  2019 Feb;12(1):46-56. 10.0000/jkccn.2019.12.1.46.

Identifying Minimum Data Sets of Oral Mucous Integrity Assessment for Documentation Systematization

Affiliations
  • 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.

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.

Keyword

Oral health; Oral ulcer; Oral hygiene; Nursing records
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