需要用户友好的审计工具:调查营养师对临床文档审计工具的使用和要求
Fabienne Schaller1,2, Elin Lövestam3, Sandra Jent1
1Division of Nutrition and Dietetics, Department of Health Professions, Bern University of Applied Sciences, Bern, Switzerland.
概括
临床文档审计在饮食学中并不普遍,但可以改善患者的护理. 营养学家需要更好的培训,基于网络的工具和明确的最佳实践,以进行有效的审计和加强营养护理.
科学领域:
- 营养与饮食学 营养与饮食学
- 改善医疗保健质量 改善医疗保健质量
- 临床文档 临床文档
背景情况:
- 高质量的临床文档对于患者的安全和护理至关重要.
- 标准化文档,如营养护理过程 (NCP),面临着影响患者结果和沟通的挑战.
- 临床文档审计可以提高质量,但工具使用和营养师需求的研究不足.
研究的目的:
- 调查营养学家在国际上使用临床文档审计工具的情况.
- 确定营养学家对有效临床文档审计工具的需求.
主要方法:
- 在16个国家向154名饮食师分发了一项定量,横截面的在线调查.
- 该调查使用了26项调查问卷来收集有关审计工具使用,目的,首选格式以及障碍/助力因素的数据.
- 使用了描述性和推断性的统计分析.
主要成果:
- 53%的受访者报告说,他们在工作场所进行了临床文档审计,主要是为了提高质量和加强NCP.
- 审计的关键推动因素包括管理支持和培训;障碍包括缺乏知识和时间.
- 虽然目前使用纸质或基于文件的工具,51%的受访者更喜欢网络应用程序以供未来使用.
结论:
- 临床文档审计在饮食学方面发展不足,但有可能提高文档质量.
- 营养师需要最佳实践,教育资源和用户友好的,基于网络的工具,以进行有效的审计.
- 未来的研究应该集中在工具验证,障碍探索和临床文档审计中的AI应用上.
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