Kinsman Leigh
LaTrobe University, Bendigo, Victoria, Australia.
Nurs Stand. 2004;18(18):33-5.
Clinical pathways have been developed to guide evidence-based practice in health care. The documented use of a clinical pathway by clinicians can be measured by chart audit and used effectively as part of the quality improvement process. The application of a rigorous process of collecting data for quality improvement adds further evidence to the quality improvement process. This article describes a chart audit methodology developed and implemented to measure documented compliance with a myocardial infarction clinical pathway used in an acute hospital.
The results informed a quality improvement process where documented use of the clinical pathway increased from 23 per cent to 58 per cent (p = 0.000). The chart audit methodology described was a key component in this successful quality improvement initiative.
临床路径已被开发用于指导医疗保健中的循证实践。临床医生对临床路径的记录使用情况可通过病历审核来衡量，并作为质量改进过程的一部分得到有效利用。为质量改进收集数据的严格过程的应用为质量改进过程增添了更多证据。本文描述了一种为衡量急性医院中使用的心肌梗死临床路径的记录依从性而开发和实施的病历审核方法。
结果为质量改进过程提供了依据，在此过程中，临床路径的记录使用从23%提高到了58%（p = 0.000）。所描述的病历审核方法是这一成功的质量改进举措的关键组成部分。
