加强第三级创伤中心上肢专家团队会议的文档
Uday Mahajan1, Moheeb Gadullah1, Raghunaathan Rangan1
1Trauma and Orthopaedics, Queen Elizabeth Hospital Birmingham, Birmingham, GBR.
在专家团队会议中实施结构化电子病历 (EPR) 文档,大大提高了记录的完整性和可访问性. 这提高了复杂创伤病例的患者安全和临床治理.
科学领域:
- 创伤外科手术是什么
- 医疗信息学 医疗信息学
- 质量改善 质量改善
背景情况:
- 专家团队会议对于复杂的创伤病例管理至关重要.
- 不准确的文档可能导致错误,信息丢失,并影响患者的安全.
- 目前的非正式记录方法是不够的.
研究的目的:
- 在专家团队会议上提高文档完整性和可访问性.
- 通过更好的记录管理,加强患者安全和临床治理.
- 评估结构化,EPR集成的文档系统的影响.
主要方法:
- 在第三级创伤中心进行了一项质量改进项目.
- 干预措施包括结构化文档模板和EPR集成.
- 再审计评估了文件的完整性和干预后的好处.
主要成果:
- 基线:没有复杂的患者结果记录在EPR中.
- 干预后:89%的复杂病例在EPR中记录了结果.
- 该系统改善了可访问性,后续和临床治理.
结论:
- 结构化,EPR集成的文档显著提高了记录的完整性和可访问性.
- 这种方法支持更安全的患者移交,并加强临床治理.
- 该框架可以在各个子专业领域应用,以标准化文档和提高患者安全.
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