改进电子健康记录的文档和使用,以促进基于证据的儿科护理
Lance Till1, Julie Leis1, Kimberly McCombs-Thornton1
1James Bell Associates (JBA), Arlington, VA, United States.
Journal of pediatric psychology
|August 22, 2024
概括
提高电子健康记录 (EHR) 改善了健康步骤 (HS) 计划的儿科护理数据质量. 虽然电子健康记录已更新,但需要可扩展的数字解决方案,以持续改善儿童健康结果.
科学领域:
- 儿科初级护理 儿科初级护理
- 医疗信息学 医疗信息学
- 改善临床质量 改善临床质量
背景情况:
- 电子健康记录 (EHR) 往往缺乏用于实施国家儿科临床指南的功能,例如美国儿科学会光明未来指南.
- 基于证据的儿科初级保健计划HealthySteps (HS) 计划是改善护理服务的典范.
研究的目的:
- 加强儿科电子健康记录,以更好地支持健康步骤计划和国家临床指南.
- 确定与儿科初级保健机构的电子健康记录增强相关的促进者和障碍.
- 提高临床数据的质量和可提取性,以实现基于证据的实践和计划实施.
主要方法:
- 三个不同的HealthySteps网站参与其中,获得数据收集和EHR更新的技术援助.
- 综合性评估利用行政记录,调查和采访进行过程评估和结果监测.
- 通过测量随着时间的推移对文档的改进和缺失数据的减少来评估数据质量.
主要成果:
- 所有参与站点都成功增强了他们的电子健康记录系统,尽管仍然需要补充系统来协调护理.
- 在数据文档中观察到显著的改进,如社会情绪查等关键指标的缺失数据显著减少.
- 提高EHR的关键促进因素包括强有力的组织支持,领导力承诺和能力建设倡议.
结论:
- 儿科实践可以修改EHR以更好地与HS和光明未来等计划保持一致,但这需要大量的时间和资源.
- 该研究强调需要更具可扩展性的数字解决方案,以有效地更新电子健康记录,并为儿童和家庭带来更好的临床护理和结果.
相关概念视频
01:30Methods of Documentation VII: EMR
827
Electronic Medical Records (EMRs) primarily center around electronically documenting patients' health information within a single healthcare organization or practice. They contain essential clinical data related to a patient's medical history, diagnoses, medications, treatment plans, lab results, and other pertinent information relevant to the specific encounter or episode of care. EMRs are designed to streamline documentation and workflow processes within individual healthcare...
827
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
01:20Introduction to Documentation and Reporting
2.0K
Documentation is the systematic process of formally recording, maintaining, and communicating information.
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive...
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive...
2.0K
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
01:23Methods 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
01:26Guidelines 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