Wainwright Gail A, Stehly Christy D, Wittmann-Price Ruth A
St Luke's Level 1 Regional Resource Trauma Center, Bethlehem, PA 18015, USA.
J Trauma Nurs. 2008 Jan-Mar;15(1):16-8. doi: 10.1097/01.JTN.0000315784.27837.ba.
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%.
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%。