提高血管外科手术手术笔记的质量:回顾性分析
Munzir Akasha1, Ahmmad Alfatih1, Mohamedali Mohamed2
1Department of Vascular Surgery, University Hospital Galway, Galway, IRL.
Cureus
|March 26, 2024
概括
在血管外科手术中改善手术笔记质量可以提高患者的护理. 员工教育,检查清单和数字系统显著提高了文档准确性和记录上传.
科学领域:
- 医疗信息学 医疗信息学
- 改善外科手术的质量
- 医疗保健文档 医疗保健文档
背景情况:
- 操作说明中不准确或缺少的信息会带来临床,伦理和医疗法律风险.
- 操作笔记要求在手术后立即及时,清晰和全面地收集数据.
- 提高手术文档的质量对于患者安全和记录完整性至关重要.
研究的目的:
- 识别和实施改善血管外科手术笔记质量的策略.
- 评估干预措施对手术记录完整性和准确性的影响.
- 增加操作笔记的数字上传到电子患者记录系统.
主要方法:
- 从血管外科手术患者的96个手术笔记的回顾性分析.
- 与爱尔兰皇家外科医生学院 (RCSI) 标准进行比较.
- 实施干预措施,包括员工教育,海报检查清单和扫描仪安装以上传数字记录.
主要成果:
- 在文件细节中观察到的显著改进:日期,程序,人员,手术细节,诊断,并发症和关闭技术.
- 在成功将操作笔记上传到EVOLVE数字患者记录系统中显著增加.
- 在外科手术文档的多个关键元素中提高完整性和准确性.
结论:
- 工作人员教育,视觉辅助工具 (海报) 和可访问技术 (扫描仪) 有效地提高了操作笔记的质量.
- 对操作笔记的结构化方法对于增强患者护理至关重要.
- 手术记录的数字化整合简化了流程,并提高了数据的可访问性.
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