修改护士培训计划对电子病历表格和评估完成率的影响
Andon M Ware1, Donal Murray, Norman W Gill
1Author Affiliation: Department of Health, Human Function and Rehabilitation Sciences, School of Medicine and Health Sciences, George Washington University, Washington, DC.
Computers, informatics, nursing : CIN
|February 12, 2025
概括
一个经过修改的电子病历培训计划显著提高了熟练护理机构护士的文件完成率. 该计划提高了关键形式的熟练程度,使完成率提高了42%至70%.
科学领域:
- 医疗保健管理的管理
- 护理信息学 护理信息学
- 改善临床文档 改善临床文档
背景情况:
- 电子医疗记录 (EMR) 系统对于患者护理和设施运营至关重要.
- 一致和准确的文档对于高质量的患者结果和监管合规性至关重要.
- 文件填写方面的差距可能会对熟练护理机构的患者安全和运营效率产生负面影响.
研究的目的:
- 评估修改后的培训计划对提高EMR文档完成率的有效性.
- 评估针对性培训对护士熟练使用关键文档形式的影响.
- 识别技能护理机构文档化实践的潜在改进.
主要方法:
- 追溯研究分析了来自八个熟练护理机构的EMR数据.
- 实施为期一周的EMR培训计划,重点关注五个关键评估形式.
- 从实施前3个月的基线与实施后3个月的基线,比较文档完成率.
- 在研究样本中包括47名护士.
- 使用描述性和推断性统计数据进行统计分析,包括对对的t测试.
主要成果:
- 在所有五个目标表格中观察到文档完成率的显著平均改善 (P < .001).
- 文件完成率大幅增加,在培训后从42%到70%不等.
- 修改后的培训计划对护士记录实践产生了积极影响.
结论:
- 修改后的EMR培训计划导致技术护理机构的文档完成率大幅提高.
- 有针对性的EMR培训可以提高护士的技能和遵守基本文档要求.
- 虽然无法最终推断因果关系,但研究结果表明,这种培训干预措施有利于改善医疗保健文档.
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