缺陷工作流程:利用电子医疗记录来改善对护理点超声波文档的遵守
Courtney M Smalley1, Molly Gourash2, Brittany Rooney2
1Department of Emergency Medicine, Cleveland Clinic Health System, Cleveland, OH, United States of America; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States of America.
实施电子医疗记录 (EMR) 缺陷工作流程显著改善了急诊部的护理点超声波 (POCUS) 文档合规性和计费. 这种简单的系统减少了3.0%的图表缺陷.
科学领域:
- 紧急医疗 紧急医疗
- 医疗信息学 医疗信息学
- 超声波技术 超声波技术 超声波技术
背景情况:
- 护理点超声波 (POCUS) 是急诊室 (ED) 的标准工具.
- 虽然图像捕捉是常见的,但POCUS研究的文档合规性仍然是繁忙的ED中面临的挑战.
- 改善POCUS文档对于准确的计费和患者护理至关重要.
研究的目的:
- 实施和评估一个简单的电子医疗记录 (EMR) 缺陷工作流程.
- 增强POCUS文档的捕获,并改进计费流程.
- 为了减少大型医疗保健系统的文档缺陷.
主要方法:
- 对12个ED的5013个POCUS研究进行了回顾性审查.
- 一个POCUS缺陷工作流,使用自动化在篮子中的消息,在2023年6月实施.
- 对程序文档的图表缺陷进行了干预前后的比较.
主要成果:
- 这项研究包括42%的研究之前和58%的工作流实施后.
- 观察到程序说明缺陷的绝对减少3.0%.
- 在干预后,缺乏率从4.44%降至1.45%.
结论:
- 实施的POCUS缺陷工作流成功改善了文档合规性.
- 这种工作流改善了POCUS研究计费,并减少了迟到的图表通知.
- 该系统可适应使用POCUS的任何医疗专业,并建议用于大型医疗保健系统.
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