改善发作频率的文档和分类
Poojith Nuthalapati1, Lionel Thomas1, Maria A Donahue1
1Department of Neurology (PN, MAD, LMVRM), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neurology (LT, SD, JRS, JP), University of Colorado School of Medicine, Aurora; Department of Pediatrics (JB), Cumming School of Medicine, University of Calgary, AB, CA; and Mission Outcomes Team (BEF), Epilepsy Foundation, Landover, MD.
实施标准化的电子健康记录 (EHR) 流表显著改善了发作记录. 这项质量改善计划加强了对发作频率,分类和最后一次发作日期的跟踪,以改善患者护理.
科学领域:
- 神经学 神经学
- 改善临床质量 改善临床质量
- 医疗信息学 医疗信息学
背景情况:
- 准确的发作数据对于治疗评估和护理质量跟踪至关重要.
- 目前关于扣押频率,分类和最后一次扣押日期的文件编制实践是不理想的.
- 需要提高质量,以提高临床数据的可靠性.
研究的目的:
- 为了增加发作频率的文档,国际病联盟 (ILAE) 的发作分类,以及最后一次发作的日期.
- 实施和评估一个标准化的电子健康记录 (EHR) 流表,以改善数据收集.
主要方法:
- 调查了病学家关于他们关于发作频率,ILAE分类和最后一次发作日期的记录习惯.
- 在4个月的时间里,每周收集基线文档数据.
- 实施了基于学习医疗保健系统 (ELHS) 标准的新EHR流表,并在6个月内评估了其影响.
主要成果:
- 基线记录率是:发作频率 (83%),ILAE分类 (33%) 和最后一次发作日期 (35%).
- 病学家认为的记录率高于实际基线数据.
- 在EHR流表实施后,所有关键指标的文档在用户中接近100%.
结论:
- 一个标准化,用户友好的EHR工具可以大大改善关键指标的文档.
- 简单的干预可以使临床上有意义的数据收集在治疗中的实质性改进.
- 改进的文档支持更好的治疗策略和诊所的护理质量跟踪.
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