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额外所需的护理文档与患者结果之间的关系:一个范围审查
Rachel Lee1, Jennifer A Thate2, Jennifer Withall3
1Department of Biomedical Informatics, Columbia University, New York, United States.
Applied clinical informatics
|March 19, 2025
概括
证据将额外的必要护理文档与改善患者结果联系在一起的证据很弱. 大多数研究重点关注合规性,而那些报告积极结果的研究往往缺乏高质量的证据,这表明需要重新评估文档负担.
科学领域:
- 护理信息学 护理信息学
- 改善医疗保健质量 改善医疗保健质量
- 基于证据的实践.
背景情况:
- 护理文档在临床沟通和护理协调中起着至关重要的作用.
- 为了合规性和次要用途,通常会实施额外的文档要求,这可能会增加护士的负担.
- 在了解增加所需护理文件对患者结果的直接影响方面存在差距.
研究的目的:
- 综合和描述当前关于添加所需电子护理文档和改善患者结果之间的关系的证据.
- 在住院医院环境中评估该领域现有研究的质量.
主要方法:
- 从2011年1月到2023年5月,在主要数据库 (PubMed,CINAHL,Web of Science,Embase) 进行了全面的文献搜索.
- 研究被选为相关的额外的必要护理文档和患者的结果.
- 根据资格标准,两位作者独立审查了标题,摘要和全文.
主要成果:
- 在包括的47项研究中,57.4%的研究仅集中在过程测量上 (例如,合规),而42.6%的研究包括患者结果测量 (例如,感染率,停留时间).
- 仅有45%的包括患者结局的研究报告了统计学上显著的积极关系.
- 证据的整体质量很低,大多数是质量改善研究,只有一个随机对照试验.
结论:
- 增加所需的护理文档和更好的患者结果之间的假设联系没有得到高质量的经验证据的支持.
- 数量有限的重大发现和方法上的缺陷凸显了需要批判性地检查文档实践的必要性.
- 重点应该转向确定真正有利于患者的文档,而不是仅仅增加行政负担.
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