Suppr超能文献

急诊护士文件记录改进工具

Emergency Nurse Documentation Improvement Tool.

作者信息

Wainwright Gail A, Stehly Christy D, Wittmann-Price Ruth A

机构信息

St Luke's Level 1 Regional Resource Trauma Center, Bethlehem, PA 18015, USA.

出版信息

J Trauma Nurs. 2008 Jan-Mar;15(1):16-8. doi: 10.1097/01.JTN.0000315784.27837.ba.

Abstract

Nursing documentation for trauma resuscitation has improved significantly at our level I trauma center because of the introduction of our Emergency Nurse Documentation Improvement Tool (END-IT). The END-IT system was implemented as a performance improvement model and utilizes existing computer software. It provides quick computerized feedback to professional nurses when documentation of trauma cases needs further attention. The feedback is provided in written form and uses peer mentoring to improve accountability in documentation. The program has been successful and has decreased documentation omissions and mistakes by 21%.

摘要

由于我们引入了急诊护士文档改进工具(END-IT),我们一级创伤中心的创伤复苏护理文档有了显著改善。END-IT系统作为一种绩效改进模式实施,并利用现有的计算机软件。当创伤病例文档需要进一步关注时,它会为专业护士提供快速的计算机化反馈。反馈以书面形式提供,并利用同行指导来提高文档记录的问责制。该项目取得了成功,文档遗漏和错误减少了21%。

相似文献

1
Emergency Nurse Documentation Improvement Tool.
J Trauma Nurs. 2008 Jan-Mar;15(1):16-8. doi: 10.1097/01.JTN.0000315784.27837.ba.
2
Putting policy into practice: pre- and posttests of implementing standardized languages for nursing documentation.
J Clin Nurs. 2007 Oct;16(10):1826-38. doi: 10.1111/j.1365-2702.2007.01836.x.
3
Interdisciplinary collaboration and the electronic medical record.
Pediatr Nurs. 2008 May-Jun;34(3):225-7, 240.
5
Electronic documentation of trauma resuscitations at a level 1 pediatric trauma center.
J Trauma Nurs. 2012 Apr-Jun;19(2):76-9. doi: 10.1097/JTN.0b013e31825629ab.
6
Using self-study modules to improve wound care documentation by the staff nurse.
J Nurses Staff Dev. 2009 Jul-Aug;25(4):E1-4. doi: 10.1097/NND.0b013e3181ae1445.
7
Improved quality of nursing documentation: results of a nursing diagnoses, interventions, and outcomes implementation study.
Int J Nurs Terminol Classif. 2007 Jan-Mar;18(1):5-17. doi: 10.1111/j.1744-618X.2007.00043.x.

文献AI研究员

20分钟写一篇综述,助力文献阅读效率提升50倍。

立即体验

用中文搜PubMed

大模型驱动的PubMed中文搜索引擎

马上搜索

文档翻译

学术文献翻译模型,支持多种主流文档格式。

立即体验