药剂师主导的抗凝疗诊所与医生主导的抗凝疗诊所之间的医学文档比较:一项回顾性研究
Mansour Almuqbil1, Haya Alturki2, Lobna Al Juffali1
1Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia.
概括
药剂师在抗凝血诊所提供比医生更全面的医疗记录文档. 在所有医疗保健提供者之间标准化文档可以提高电子健康记录的一致性.
科学领域:
- 医疗文件 医疗文件
- 临床药房 临床药房
- 患者安全 患者安全
背景情况:
- 高质量的医疗文档对于安全的患者护理至关重要.
- 抗凝血疗法诊所需要严格的记录管理,以确保有效的患者管理.
- 文档标准的变化可能会影响护理质量.
研究的目的:
- 评估抗凝血诊所医疗记录的标准.
- 调查药剂师主导和医生主导诊所之间的文档差异.
- 确定临床文档实践需要改进的领域.
主要方法:
- 电子健康记录 (EHR) 的回顾性横截面分析.
- 包括来自药剂师领导和医生领导的抗凝血诊所的患者 (2020年10月至12月).
- 用标准化评分系统评估文档质量,并对其进行分类 (非常好到非常差).
主要成果:
- 与医生 (18%) 相比,药剂师的文档质量明显更高 (54%非常好).
- 医生对药物-药物和药物-食物相互作用的记录比药剂师少.
- 药剂师比医生更密切地遵守随访协议,尽管治疗计划的文档类似.
结论:
- 药剂师在抗凝血诊所提供更全面的文档.
- 在电子健康记录中推统一的文档标准,以确保跨学科的一致性.
- 加强文档实践可以改善患者安全和护理协调.
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