预填充交换报告的力量:优化护士与护士之间的沟通和患者体验
Meredith Kuhlmann1, Olawunmi Obisesan, Lauren McGinnis
1Author Affiliations: Missouri Baptist Medical Center (Ms Kuhlmann, Dr Obisesan, Ms McGinnis, and Dr Otey); and Goldfarb School of Nursing at Barnes Jewish College (Dr Otey), St Louis, MO.
Computers, informatics, nursing : CIN
|June 11, 2025
概括
实施电子健康记录预填充的护士交接工具显著提高了沟通清晰度和效率. 这导致患者对护士沟通的满意度显著增加,改善了整体护理.
科学领域:
- 护理信息学 护理信息学
- 患者安全 患者安全
- 医疗保健通讯 医疗保健通讯
背景情况:
- 不有效的护士对护士的交接会对患者的安全和护理的连续性产生负面影响.
- 标准化通信协议对于有效的患者护理过渡至关重要.
研究的目的:
- 评估电子健康记录 (EHR) 预填充护士交付工具的影响.
- 评估沟通质量,效率和患者干预后体验的变化.
主要方法:
- 采用了测试前后测试准实验设计.
- 评估了护士对移交完整性和持续时间的看法.
- 用医院消费者对医疗保健提供者和系统 (HCAHPS) 的评估调查来衡量患者满意度.
主要成果:
- 护士报告说,信息的完整性,清晰度以及交付时间的缩短显著改善.
- 该干预导致患者对护士沟通清晰度的满意度增加了20.10%.
- 预填充EHR的数据似乎减少了移交期间的遗漏和错误.
结论:
- 标准化,EHR预填充的交付报告可以提高护士的沟通和工作流的效率.
- 这种干预措施有望提高患者的安全性和满意度.
- 优化护士交接流程对于提供优质医疗保健至关重要.
相关概念视频
Types of Reports I: Hands-off Report
890
A hand-off report, also known as a change-of-shift report, is a crucial nursing process that ensures the smooth transition of patient care responsibilities between nursing staff.
Following are the key components and categories of hand-off reports:
Purpose and Process:
Following are the key components and categories of hand-off reports:
Purpose and Process:
890
SBAR I: Understanding the Concept
4.4K
Effective communication among healthcare professionals during hand-off reporting is essential to delivering safe and continuous patient care. Common professional interactions include reports to healthcare team members, hand-off, and transfer reports. Nurses routinely report information to other healthcare team members and also urgently contact healthcare providers to report changes in patient status.
Standardized methods of communication have been developed to ensure that information is...
Standardized methods of communication have been developed to ensure that information is...
4.4K
Nurses' Legal Responsibilities II
687
Establishing a secure, collaborative nurse-patient relationship is crucial for delivering high-quality care. This relationship, founded on trust, respect, and honesty, enhances the patient's comfort and willingness to share vital health information. For example, a nurse who listens actively and without judgment provides clear information about health conditions and treatment options and respects patient decisions, which builds a trusting relationship.
Communication between nurses and...
Communication between nurses and...
687
Formats for Nursing Documentation
918
Nursing documentation encompasses various formats designed to capture precise patient data, facilitate communication among healthcare team members, and ensure comprehensive and accurate patient records. Let's explore each of these formats in detail:
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history,...
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history,...
918
Introduction to Documentation and Reporting
2.0K
Documentation is the systematic process of formally recording, maintaining, and communicating information.
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive...
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive...
2.0K
Types of Reports III: Telephone and Verbal Reports
727
Telephone and Verbal Reports in healthcare settings are two communication methods for conveying therapeutic instructions from healthcare providers to nurses or other healthcare staff.
Here's an overview of each type:
Telephone Orders
Here's an overview of each type:
Telephone Orders
727


