护士在急性医疗环境中使用电子医疗记录中的护理护理计划的经验:混合方法研究
Rebecca Miriam Jedwab1, Isabella McDonald, Bernice Redley
1Author Affiliations: Nursing and Midwifery Informatics, EMR & Informatics Program, Monash Health, Clayton, Victoria, and Deakin University School of Nursing and Midwifery, Geelong (Dr Jedwab and Ms Dobroff); Monash Health, Clayton (Ms McDonald); Victorian Health Complaints Commissioner, Melbourne (Dr Redley); and School of Nursing and Midwifery (Dr Redley) and School of Nursing and Midwifery and Centre for Quality and Patient Safety Research in the Institute for Health Transformation (Dr Mekonnen), Deakin University, Geelong, Australia.
电子病历 (EMR) 护理计划可以帮助患者护理,但护士面临着挑战. 提高EMR的可用性,并将其与护理工作流程保持一致,对于有效的文档和患者护理提供至关重要.
科学领域:
- 护理信息学 护理信息学
- 卫生信息系统 卫生信息系统
- 临床文档 临床文档
背景情况:
- 电子医疗记录 (EMR) 系统为结构化护理计划提供了潜力.
- 关于护士与EMR护理计划的实际经验,存在文献上的差距.
- 了解这些经验对于优化EMR功能在临床环境中至关重要.
研究的目的:
- 探索护士在EMR中对护理计划的文件遵守情况.
- 识别影响护理计划文件的障碍和推动因素.
- 为提高护士对EMR护理计划的使用提供建议.
主要方法:
- 一种混合方法的方法,结合了定量审计数据和定性重点小组.
- 对142个患者记录进行审计,以启动护理计划和文件.
- 六个焦点小组与护士一起探索经验和感知.
主要成果:
- 大多数患者 (84.5%) 启动了EMR护理计划;然而,只有44.4%在24小时内启动.
- 针对护理计划的文档非常低 (48小时内2.11%).
- 定性数据揭示了"注意差距"和"让它为我们工作"的主题,突出了工作流的挑战和系统调整的必要性.
结论:
- 在护士对EMR护理计划的理解和应用方面存在显著的差异.
- 医疗护理计划的可用性和设计必须与护理工作流程无结合.
- 建议侧重于使EMR文档与临床实践保持一致,以改善患者护理的规划和交付.
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