标准化EHR集成交付报告对手术内沟通结果的影响
Joanna Abraham1,2, Christopher R King1, Lavanya Pedamallu1
1Department of Anesthesiology, Washington University School of Medicine, St Louis, MO 63110, United States.
概括
一个标准化的电子健康记录集成的交付报告显著改善了手术内信息传输和临床医生的满意度. 这种结构化的方法提高了患者的安全性,并在重症监护过渡期间简化了沟通.
科学领域:
- 麻醉学 麻醉学
- 医疗信息学 医疗信息学
- 患者安全 患者安全
背景情况:
- 在外科手术期间的交接对于患者的安全至关重要.
- 目前的非结构化交付方法可能会导致信息缺口和错误.
研究的目的:
- 评估标准化电子健康记录 (EHR) 集成的手续报告的有效性和可实施性,用于手术内过渡.
- 为了比较使用结构化报告与非结构化笔记的交付质量.
主要方法:
- 采用了干预前后研究设计.
- 混合方法包括一般观察,影视,调查和麻醉临床医生的采访.
- 分析了151个手术内移交 (78个干预前,73个干预后).
主要成果:
- 综合EHR的交付报告显著增加了有关气道管理,手术内过程和潜在问题的信息传输.
- 临床医生的满意度得分提高了信息的清晰度,简洁性和传递性.
- 交换时间显著减少,发送方和接收方均报告错误机会减少.
结论:
- 标准化的EHR集成的移交报告对于手术内移交是有效和高效的.
- 结构化格式促进了准确的信息传输,减少了错误,并简化了沟通.
- 移交的标准化有助于安全和高质量的手术内护理.
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