将aSSKINg框架集成到电子病例记录中:一个质量改进项目
Susan Martin1, Samantha Holloway2, Emily Watts3
1Tissue Viability Nurse Specialist Sussex Community NHS Foundation Trust.
British journal of community nursing
|December 10, 2024
概括
将aSSKINg框架落实到电子病例记录中,改善了压力 (PU) 风险评估的护理文档. 合规性增加,特别是在初步评估和重新定位建议方面,提高了患者护理.
科学领域:
- 护理 护理 护理
- 临床信息学 临床信息学
- 提高质量 提高质量
背景情况:
- 准确的压力 (PU) 风险评估和记录在临床实践中至关重要.
- 尽管有指导方针,但对PU风险的护理文档仍然不一致.
- 之前的研究确定了PU预防包的证据,并在社区环境中审计了合规性.
研究的目的:
- 通过将aSSKINg框架实施到电子患者记录 (EPR) 中,增强对PU风险的护理文档.
- 评估EPR整合对遵守aSSKINg预防PU框架的影响.
主要方法:
- 一个涉及临床审计的质量改进项目.
- 将aSSKINg框架模板实施到EPR中.
- 审计有两个部分:试点阶段 (2023年2月至4月) 和后续审计 (2023年11月至2024年1月).
- 逐步推广到成年社区护理,养老院主妇和紧急社区响应团队的试点后.
主要成果:
- 对aSSKINg框架的整体遵守显著改善了后EPR实施.
- 在完成PURPOSE-T的首次访问,全皮肤评估和重新定位建议中发现的关键改进.
- 该EPR模板为各种社区护理团队提供了更好的文档.
结论:
- 将aSSKINg框架整合到EPR中是一种有效的策略,以改善PU风险的护理文档.
- 改进的文档支持更好地遵守PU预防指南.
- 这一质量改进倡议证明了临床信息学在患者安全方面的价值.
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