过程标准化接触标签,以描述门诊护理药剂师活动的过程标准化
Carly Gabriel1, Clinical Pharmacist1, Trisha A Miller2
1UPMC Presbyterian Shadyside. Department of Pharmacy, Ambulatory Services Pittsburgh, PA.
标准化电子医疗记录 (EMR) 遇到的原因是改善了药剂师活动的文档. 这种结构化数据方法提高了患者护理服务的特征,以便更好地分析和报告.
科学领域:
- 医疗信息学 医疗信息学
- 药房实践 在药房实践.
- 临床文档 临床文档
背景情况:
- 电子医疗记录 (EMR) 中的结构化文档对于药剂师的患者护理活动至关重要,包括连续性,计费和结果.
- 标准化相遇理由字段对于分析药剂师活动而不是进行广泛的图表审查至关重要.
研究的目的:
- 为了在EMR的遭遇理由领域中标准化门诊护理药剂师遭遇标签.
- 创建一个系统范围采用的模板,以更好地描述各级药剂师活动.
主要方法:
- 在实施新的标准化程序之前和之后,从药剂师遭遇中收集和分析了遭遇原因条目.
- 所需的程序,指定每个遭遇的指示和行动/服务.
- 药剂师接受了关于新程序的培训,并使用描述性统计数据比较了实施前和后的数据.
主要成果:
- 一般的,没有信息的遭遇原因条目显著下降,从实施前的18.6%降至实施后的3.9%.
- 在排除抗凝血药物接触后,缺乏原因的遭遇的百分比从26.8%降至12.1%.
- 在经过实施后的遭遇数量,独特的患者或疾病状态上没有观察到显著的变化.
结论:
- 实施标准化程序的遭遇原因标签导致更强大的和一致的数据来描述药剂师的服务.
- 这种结构化数据方法为具有有限分析资源的实践提供了一个有价值的工具,用于开发服务指标.
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