改善临床工作流程:一个质量改进项目关于录取文档标准化的标准化
Aarsh Sathia1, Vikrant Ghadge2
1General Surgery, Bharatratna Dr Babasaheb Ambedkar Municipal General Hospital, Mumbai, IND.
Cureus
|October 20, 2025
概括
实施标准化的入院形式显著改善了外科入院笔记的完整性. 关键的文档领域,如病史和过去的医学史,取得了实质性进展,提高了患者的安全性.
科学领域:
- 医疗信息学 医疗信息学
- 改善医疗保健质量 改善医疗保健质量
- 手术患者护理手术患者护理
背景情况:
- 完整的入院笔记对于手术环境中的患者安全和护理连续性至关重要.
- 一项基线审计揭示了手术入院记录中的重大遗漏,包括病史 (HOPI) 和病史 (PMH).
- 现有的记录实践不足,需要进行干预,以提高记录的完整性.
研究的目的:
- 评估标准化入院形式对手术入院笔记完整性的影响.
- 通过反复改进形式的医疗文档来确定改善的关键领域.
- 通过优化入院记录质量来提高患者安全和护理连续性.
主要方法:
- 两个计划做研究行为 (P.D.S.A.) 周期是在2025年4月至5月期间进行的.
- 基于用户反,一个标准化的入学形式被代地实施和改进.
- 在基线时,在循环1之后,在循环2之后,对40个外科入院笔记进行了图表审查,以评估特定领域的文档完整性.
主要成果:
- 在循环1之后,病史 (HOPI) 文档改进到100%,检查结果提高到97.5%.
- 循环2后,过去的病史 (PMH) 显著改善至85% (p<0.001),视觉辅助文档增加至75% (p=0.022).
- 调查文件和管理计划在整个研究期间保持在100%的水平.
结论:
- 循序渐进地实施结构化的入院形式有效地提高了外科入院笔记的完整性.
- 标准化模板是一种可靠的工具,可以提高手术环境中的医疗文档质量.
- 这些发现支持广泛采用标准化程序,以改善手术入院记录和患者护理.
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