对全面的CARE记录的实施评估,以减少在医院获得的并发症:混合方法前后研究
Rebecca Leigh Jessup1,2,3, Maree Glynn4, Deborah Zilm4
1Victorian Centre for Virtual Health Research, Northern Health, Epping, Victoria, Australia rebecca.jessup@nh.org.au.
综合评估和风险评估 (CARE) 记录通过减少跌倒和压力伤害,提高了患者安全. 然而,它增加了员工的文件处理时间,并要求平衡结构化流程与临床判断.
科学领域:
- 改善医疗保健质量 改善医疗保健质量
- 患者安全研究的研究.
- 医疗信息学 医疗信息学
背景情况:
- 澳大利亚国家安全和质量卫生服务标准要求提供全面的护理.
- 标准5要求进行结构化的评估和护理规划.
- 综合评估和风险评估 (CARE) 记录是为了满足这些要求而开发的.
研究的目的:
- 评估CARE记录对患者安全和护理质量的影响.
- 探索工作人员和患者在CARE记录实施中的经验.
主要方法:
- 混合方法前后评估.
- 医院数据的定量分析 (跌倒,压力损伤,医院获得的并发症).
- 来自工作人员调查和患者访谈的定性数据.
主要成果:
- 总体下跌和压力损伤的减少.
- 增加了关于妄想,营养不良,暴力和自我伤害的记录.
- 工作人员报告工作量增加,但沟通改善;患者对一些担忧感到满意.
结论:
- CARE记录的实施与改善的患者安全结果有关.
- 实施的挑战包括增加的文档化时间.
- 将结构化评估与临床判断相平衡,对于符合5标准至关重要.
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