医疗记录中的新领域的价值,以提高质量
Theodore Poufos1,2, Georgios Rigakos1,2, Stefanos Labropoulos1,2
1Hygeia Hospital, 3rd Oncology Department, Marousi, Greece.
在癌症护理中实施结构化文档显著改善了患者的随访和质量评分. 这增强了医疗记录实践,促进了对瘤病人的更安全,标准化的护理文化.
科学领域:
- 在瘤学瘤学.
- 改善医疗保健质量 改善医疗保健质量
- 医疗文件 医疗文件
背景情况:
- 有效的文档对于患者安全和癌症护理经验至关重要.
- 医疗记录提示可以提高文档准确性和服务质量.
- 当代瘤学团队 (COT) 旨在通过文档更改来提高质量.
研究的目的:
- 评估医疗记录改革对私人瘤诊所护理和文档质量的影响.
- 评估实施的文档改进与在瘤实践质量倡议 (QOPI) 中的绩效之间的关联.
主要方法:
- 希腊一家私人瘤诊所COT参加了美国临床瘤学会 (ASCO) 的QOPI.
- 2014年至2019年期间,纸质患者病历发生了变化,包括疼痛,情绪健康,心理社会评估,治疗讨论,同意,药物细节,治疗目标,副作用,怀孕查,坚持和持续时间的新领域.
- 该研究分析了这些变化与COT的QOPI表现之间的关联.
主要成果:
- 结构化的患者随访形式显著改善了疼痛和情绪健康评估和文档.
- 对生育问题和烟草使用的评估以及治疗计划的文件显示,由于QOPI平均水平以上的基线表现已经很高,变化不那么剧烈.
- 医疗记录改革后,整体QOPI得分有所改善.
结论:
- 纸质医疗记录的全面改革,与QOPI标准保持一致,提高了QOPI分数.
- 改革促进了对瘤团队内更安全,更标准化,更以质量为导向的护理的文化转变.
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