护理文档框架 (SBAR,SOAP和PIE) 在加强临床交换和患者安全方面的有效性
Esthela Carolina Hidalgo Tapia1, Joanna León Yosa1, María Humbelina Olalla García2
1Nursing Education, Universidad de Cuenca, Cuenca, ECU.
Cureus
|September 15, 2025
概括
像SBAR,SOAP和PIE这样的结构化通信模型显著改善了护理人员的交换通信,减少了错误并提高了患者安全. 这些框架确保医疗保健专业人员之间更清晰,更准确的信息交换.
科学领域:
- 护理信息学 护理信息学
- 医疗保健通讯 医疗保健通讯
- 患者安全 患者安全
背景情况:
- 结构化沟通模型 (SBAR,SOAP,PIE) 对于改善护士交接和患者安全至关重要.
- 这些模型标准化了信息共享,最大限度地减少了错误,并提高了沟通效率.
研究的目的:
- 系统地审查SBAR,SOAP和PIE在提高护理人员交付质量的有效性.
- 评估这些模型对减少临床错误和改善各种临床环境中的患者安全的影响.
主要方法:
- 按照PRISMA 2020指南进行系统审查.
- 在PubMed,科学网,科克兰图书馆 (2005年1月至2025年5月) 进行文献搜索.
- 包括涉及住院护士的准实验,RCT和混合方法研究;使用Cochrane RoB 2.0,ROBINS-I和MMAT评估偏差风险.
主要成果:
- 15项研究 (中等到高质量) 符合纳入标准.
- 结构化框架显著提高了沟通的清晰度和准确性,并减少了遗漏.
- 在高急性护理方面,SBAR表现出色;在日常护理和评估方面,SOAP和PIE表现出色.
- 观察到与交付相关的错误发生率减少.
结论:
- 实施结构化护理文档可以加强跨学科的合作.
- 这些模型支持更安全的护理过渡,并有助于改善患者的治疗结果.
- 结构化沟通对于现代护理实践和患者安全至关重要.
相关概念视频
01:21Methods of Documentation III: PIE
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Problem-intervention-evaluation (PIE) is a systematic approach to documentation used in healthcare settings for clinical decision-making and patient care planning. It is a structured approach to organizing patient data based on problems, interventions, and evaluations. Here's a breakdown of its key features and considerations:
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01:29SBAR I: Understanding the Concept
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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...
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01:08Role of Communication in the Nursing Process III: Evaluation and Documentation
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A successful patient outcome depends mainly on the evaluation stage of the nursing process. Evaluation determines effectiveness by reviewing what was done previously after the completion of nursing interventions. Every time a healthcare professional steps in or administers treatment, they must reassess or evaluate the action to ensure the intended result. During the evaluation phase, there are three probable patient outcomes:
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01:28Formats for Nursing Documentation
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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,...
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01:26Guidelines for Nursing Documentation II
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Effective documentation is an integral part of nursing practice. Here are some essential guidelines to follow when documenting patient care:
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
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01:14SBAR II: Application of SBAR
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SBAR is an effective communication tool used by healthcare professionals to communicate patient information accurately. SBAR stands for Situation, Background, Assessment, and Recommendation. For a better understanding, an example is given below.
SBAR Report from a Nurse to a Health Care Provider
S: "Hello, Dr. Smith. This is Jane, RN, from the Med Surg unit. I am calling to tell you about Ms. White in Room 210, who is experiencing increased pain and redness at her incision site. Her recent...
SBAR Report from a Nurse to a Health Care Provider
S: "Hello, Dr. Smith. This is Jane, RN, from the Med Surg unit. I am calling to tell you about Ms. White in Room 210, who is experiencing increased pain and redness at her incision site. Her recent...
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