电子健康记录在医院环境中改善护士文档的策略:一个范围审查
Haustine Patt Panganiban1, Alfredo Dela Cruz, Rebecca Jedwab
1Author Affiliations: The Royal Melbourne Hospital, Parkville (Mr Panganiban and dela Cruz); The Royal Women's Hospital, Carlton (Panganiban); Australian College of Nursing, Deakin (Mr Panganiban and Dr Jedwab); and Monash Health (Jedwab), Clayton, Australia.
Computers, informatics, nursing : CIN
|March 18, 2025
概括
电子健康记录 (EHR) 策略可以改善护理文档合规性. 这次审查确定了组织变化,提醒和政策作为基于EHR的关键策略,以减少文档负担.
科学领域:
- 医疗信息学 医疗信息学
- 护理科学 护理科学
- 医疗保健管理的管理
背景情况:
- 电子健康记录 (EHR) 有助于护理,但往往会增加文档负担和违规行为.
- 现有的研究解决了文档负担,但缺乏基于EHR的改进策略的全面审查.
研究的目的:
- 进行范围审查,确定基于EHR的策略,以提高医院的护理文档.
主要方法:
- 在 MEDLINE, Web of Science 和 CINAHL 数据库中使用 PRISMA 扩展范围审查指南进行搜索.
- 包括从652个初始检索中的25个全文研究.
- 分析识别的文档问题,策略和结果.
主要成果:
- 在6个确定的文档问题中,文档合规是主要问题 (44%).
- 基于EHR的三个主要策略出现了:组织变革,最终用户提醒以及财务激励/政策.
- 超过一半 (52%) 的研究报告使用这些策略改善了文档合规性.
结论:
- 基于EHR和补充策略可以增强护理文档.
- 需要进一步的研究来评估对患者护理,文档质量和护理时间成本的影响.
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