一项研究,以确定护理文档减少在危机时期的共识
Stephanie H Hoelscher1, Susan McBride, Serena Bumpus
1Author Affiliations : Texas Tech University Health Sciences Center, Lubbock (Dr Hoelscher); The University of Texas at Tyler (Dr McBride); Texas Nurses Association, Leander (Dr Bumpus); The Gilder Company 13318 Mount Castle Dr. Dallas, Texas 75234 and Texas Tech University Health Sciences Center, Lubbock (Mr Gilder); and Belmont Abbey College 00 Belmont-Mt. Holly Road, Belmont, NC 28012 (Dr Elkind).
随着COVID-19的流行,护士的文档负担增加了. 这项研究发现了持续的文档变化和对"激增"标准的各种定义,突出了护理中需要国家标准和基于证据的实践的需要.
科学领域:
- 护理信息学 护理信息学
- 医疗保健政策 医疗保健政策
- 公共卫生危机 公共卫生危机
背景情况:
- 随着COVID-19的流行,护士的文档负担大幅增加.
- 患者数量和医疗保健政策的快速变化 (例如,1135豁免) 影响了护理文档实践.
- 护士报告了安全问题,需要国家标准和监管支持.
研究的目的:
- 在危机期间识别护理文档的修改.
- 在减少适用于超越流行病的文档负担方面找到共同点.
- 在定义"激增"标准方面达成共识.
主要方法:
- 混合方法的探索性设计.
- 对2022年2月至11月的文档模式进行调查和数据分析.
- 涉及175名北美护士领导和信息学家;分析包括描述性统计,主题分析和皮尔森相关性.
主要成果:
- 在农村和城市环境之间观察到文件变化的显著差异 (P = .02).
- 城市地区的护理计划更改的可能性更高 (OR, 4.889).
- 危机后的文档变化持续存在",激增"的定义因组织因素而异.
结论:
- 获得了修改护理文档和减少负担的见解.
- 提供了政策建议,以支持标准化,基于证据的护理实践.
- 持续的合作对于适应未来医疗保健挑战至关重要.
相关概念视频
Guidelines for Nursing Documentation II
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
Guidelines for Nursing Documentation I
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
Role of Communication in the Nursing Process III: Evaluation and Documentation
Introduction to Documentation and Reporting
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For example, a patient with a chronic...
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