在急诊部实施高级护理规划标准化文件和计费:一项回顾性队列研究
Erica Westlake1, Allison Cash2, Joseph Ragan3
1Department of Emergency Medicine, Cooper University Health Care, Camden, New Jersey; Cooper Medical School at Rowan University, Camden, New Jersey.
The Journal of emergency medicine
|November 12, 2025
概括
在急诊部 (ED) 实施模板笔记改善了高级护理计划 (ACP) 对话的文档. 这项质量改进倡议还确定了为ACP服务计费的机会.
科学领域:
- 紧急医疗 紧急医疗
- 提高质量 提高质量
- 医疗信息学 医疗信息学
背景情况:
- 高级护理规划 (ACP) 对话在急诊室 (ED) 中很常见,但经常不一致地记录和计费.
- 缺乏标准化的文档阻碍了对这些关键讨论的跟踪和报销.
研究的目的:
- 实施一个质量改进项目,以增加ACP在ED的讨论.
- 为了规范ACP对话的文档和计费流程.
主要方法:
- 在一个城市的学术中心实施了一个模板电子健康记录笔记.
- 这份备忘录包含了非洲和非洲国家和地区的文件,代理决策者和代码状态.
- 追溯图表审查分析了12个月的人口统计,临床和计费数据.
主要成果:
- 448名患者通过标准化笔记记录了ACP讨论.
- 患者平均年龄为72岁,53%为女性.
- 只有6.5%的遭遇有可计费的ACP时间,尽管38.0%为重症监护时间收费.
结论:
- 模板注释增强了编辑版中ACP文件的一致性.
- 标准化文档为非洲和非洲国家/地区的服务创造了潜在的计费机会.
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