翻转脚本:改变文档标准并为初级保健机构的药剂师建立最佳实践
Nicole Domanski1, Carmen Leung1
1Faculty of Pharmaceutical Sciences, University of British Columbia.
Innovations in pharmacy
|August 21, 2024
概括
实施新的文档工具显著减少了药剂师的笔记写作时间,减少了14分钟. 这项质量保证计划提高了效率,并减少了临床文档的负担.
科学领域:
- 药房实践 在药房实践.
- 临床文档 临床文档
- 提高质量 提高质量
背景情况:
- 临床接触记录是药房实践中持续存在的挑战.
- 有限的文献存在于药房设置文档的最佳实践.
- 学术药房诊所需要高效和有效的文档策略.
研究的目的:
- 为药剂师识别文件的促进者和障碍者.
- 为了提高咨询笔记写作的效率.
- 在学术药房诊所的最佳实践中,为记录提供信息.
主要方法:
- 一个质量保证倡议,涉及三个阶段的方法.
- 通过在线调查药剂师文档实践进行基线评估.
- 干预措施的实施,包括修订的模板,检查清单,决策树,指南和同行反研讨会.
主要成果:
- 药剂师在干预后将笔记完成时间缩短了大约14分钟.
- 在实施修订后的注释结构后,模板使用率从37%增加到100%.
- 写咨询笔记的负担显著下降.
结论:
- 干预措施有效地提高了效率,并减少了药剂师临床文档的负担.
- 结果可以指导药房教育的文档技能.
- 改进的文档实践可以使团队和初级保健机构受益.
相关概念视频
01:30Guidelines for Nursing Documentation I
1.0K
Quality documentation and reporting share essential characteristics that ensure they are practical and valuable resources for those who use them. These characteristics are:
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
1.0K
01:29Documentation in Long-Term and Home Healthcare Setting
875
Documentation in long-term care facilities and home healthcare settings is crucial for ensuring continuous, coordinated, and comprehensive care for patients. Each setting has its specific documentation processes and tools:
Long-Term Care Facilities
Long-Term Care Facilities
875
01:26Guidelines for Nursing Documentation II
1.0K
Effective documentation is an integral part of nursing practice. Here are some essential guidelines to follow when documenting patient care:
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.
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.
1.0K
01:15Methods of Documentation VI: Case Management Model
564
The case management model is a multidisciplinary approach that involves healthcare professionals from diverse disciplines, such as physicians, nurses, therapists, social workers, and pharmacists, working collaboratively to address the various needs of patients. Each healthcare professional brings unique expertise and perspectives, contributing to a more comprehensive understanding of the patient's condition and tailoring treatment plans accordingly.
For example, a patient with a chronic...
For example, a patient with a chronic...
564
01:23Methods of Documentation V: CBE
891
Charting by Exception, or CBE, is a method of documentation used in healthcare, particularly in nursing, that focuses on documenting only significant or abnormal findings rather than recording every detail. This approach aims to streamline the documentation process, improve efficiency, and ensure that healthcare providers can quickly identify deviations from normalcy in patient assessments.
In CBE, healthcare professionals establish predefined standards of practice that define what constitutes...
In CBE, healthcare professionals establish predefined standards of practice that define what constitutes...
891
01:06Legal Guidelines for Documentation
1.3K
The legal guidelines for nursing documentation are essential for ensuring accurate, professional, and ethical recording of patient care. The guidelines are discussed here:
1.3K