通过BSOAP框架评估患者进展记录文档的改进:临床审计
Basil Hamed1, Imam Mohamed2, Raghad Elsayed2
1Pediatrics, National Ribat University, Khartoum, SDN.
Cureus
|September 15, 2025
概括
实施BSOAP (背景,主观,目标,评估,计划) 框架改善了儿科护理中的医疗文档质量. 这种结构化的方法,包括培训,提高了进展记录的完整性和患者护理的连续性.
科学领域:
- 医疗文件 医疗文件
- 临床审计 临床审计
- 儿科护理 儿科护理
背景情况:
- 医疗文件对于患者护理的透明度,安全性和连续性至关重要.
- 进度笔记是医疗文档的关键组成部分.
- BSOAP (背景,主观,目标,评估,计划) 框架为文档提供了一个结构化的方法.
研究的目的:
- 评估和改进儿科部门的进展记录文档.
- 评估BSOAP框架在改善医疗文档方面的有效性.
- 确定临床文档实践需要改进的领域.
主要方法:
- 进行了为期三个周期的追溯前临床审计.
- 评估了儿科部门的511次早晨随访.
- 干预包括演讲,讨论,提醒和监督.
主要成果:
- "计划"部分最初是最少记录的.
- 讨论和患者教育是记录最少的参数.
- 生命体征和患者年龄是记录最多的参数.
- 在整个审计周期中,特别是第二和第三个周期之间,观察到所有文档组件的显著改进.
- 第二个和第三个周期的所有进展报告都采用了基于BSOAP的方法.
结论:
- BSOAP框架,再加上培训和监督,大大改善了医疗文档.
- 结构化文档框架提高了患者记录的质量和完整性.
- 有针对性的干预措施可以有效地解决临床文档实践中的缺陷.
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