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J Nurs Acad Soc. 1992 Sep;22(3):373-388. Korean. Original Article.
Chang SB .

This study was done to identify the degree of congruence between nurses and patients on patients' health problems. The purposes of this study were 1. To compare the health problems of parturient women as identified by interview and in the nursing record. 2. To compare the health problems of patients who have had gynecological surgery as identified by interview and in the nursing record. 3. To compare the health problems of chemotherapy patients as identified by interview and in the nursing record. The design of this study was a comparative descriptive design. The subjects were 205 Obstetric-Gynecologic patients. The tool for this study was an 11 item questionnaire, including one open ended question on the patient's problem during the past one day. Data was collected through interviews and an audit of the nursing records during the period from March 22, 1992 to April 29, 1992. Data was analyzed using by frequencies and percentiles. The result of this study summarized as follows : Pain was the most prevalent complaint for parturient women by interview(60.3%) and from the nursing records(83.2%). There was no record in the nursing records about the complaints of lack of information and emotional problems even though there were complaints of communication problems(17.6%) and of emotional problems(3.5%) identified in the interviews but there were more records of cardiopulmonary problems in nurses record(9.1%) than the patient interviews(3.3%). In the nursing records 25.9% of the identified records identified pain problems compared with 23.3% in the interviews. In the nursing records, 22.3% of the records identified nutrition problem as compared with 18.2% in the interview. There were only a very few emotional problem identified in the nursing records(3.7%) as compared to 18.2% in th interviews. There were no comments about communication problems in the nursing records but 5.2% of the subjects mentioned of communication problems in the patient interview. There were problems is five categories for the parturient women ; comfort, communication, activity and rest, elimination, emotions, and there were problems in ten categories for the surgery patients : comfort, elimination, communication, emotions, nutrition, cardiopulmonary, thermoregulation, physical integrity, host defense and activity / rest. There were also problems in the same ten categories for chemotherapy patients. On the other hand, in the nursing records, only comfort activity / rest, and elimination problems were identified for the parturient women, there were only seven categories of problems ; comfort, elimination, cardiopulmonary, activity / rest, and nutrition for the gynecology surgical patients, and for the chemotherapy patients, comfort, nutrition, physical integrity, cardiopulmonary, activity / rest, thermoregulation, emotion and elimination were the categories identified, and no communication problems were identified. It was found that there was low congruence between the patients' problems as identified through patient interview and as recorded in the nursing records. Therefore it can be concluded that the main content of the nursing records is the physical problems of the patients and this is not in congruence with the patients' reported problems in the emotional and communication domain.

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