Bernstein Jonathan A, Imler Daniel L, Sharek Paul, Longhurst Christopher A
Lucile Packard Children's Hospital, Palo Alto, California, USA.
Jt Comm J Qual Patient Saf. 2010 Feb;36(2):72-8. doi: 10.1016/s1553-7250(10)36013-2.
In recent years, electronic sign-out notes have been identified as a means of enhancing the effective transfer of patient care between providers. Such a tool was developed and implemented within the electronic medical record (EMR) system, and its impact on physician work flow was assessed.
A printable sign-out report was implemented within the EMR system at a tertiary academic children's hospital. Month 1 post go-live survey data were collected in June and July 2006, and 6-month post go-live survey data were collected in November and December 2006. Use of the sign-out form to document handoff data between go-live and Month 16 (September 2007) was measured using log data from the EMR. Housestaff physicians were asked to report the impact of the tool on their work flow and satisfaction with the sign-out process through a Web-based survey.
The sign-out report was steadily adopted following its introduction. Between the first and second surveys, use of EMR-integrated sign-out increased from 37% to 81% of respondents for day-to-night sign-out (chi2 = 12.79, p < .001) and from 14% to 39% for night-to-day sign-out (chi 2 = 5.08, p < .05). With increased use of the report, housestaff reported less time devoted to redundant data entry and increased satisfaction with the sign-out process.
EMR-integrated sign-out documents offer the advantages of other electronic network-accessible systems and can also incorporate information already in the medical record in an automated manner. Although the primary motivation for introducing standardized, EMR-integrated sign-out documents is to enhance the safety of patient handoffs, the perception of improved physician work flow is also a benefit of such an intervention.
近年来，电子交班记录已被视为一种加强医护人员之间有效进行患者护理交接的手段。我们在电子病历（EMR）系统中开发并应用了这样一种工具，并评估了其对医生工作流程的影响。
在一家三级学术儿童医院的EMR系统中启用了一份可打印的交班报告。2006年6月和7月收集了上线后第1个月的调查数据，2006年11月和12月收集了上线后6个月的调查数据。利用EMR的日志数据来衡量在上线至第16个月（2007年9月）期间使用交班表记录交接数据的情况。住院医师被要求通过一项基于网络的调查来报告该工具对其工作流程的影响以及对交班过程的满意度。
交班报告推出后得到了稳步采用。在第一次和第二次调查之间，参与日班至夜班交班的受访者中，使用集成在EMR中的交班记录的比例从37%增至81%（χ2 = 12.79，p < .001），参与夜班至日班交班的受访者中这一比例从14%增至39%（χ2 = 5.08，p < .05）。随着该报告使用的增加，住院医师报告称用于重复数据录入的时间减少，对交班过程的满意度提高。
集成在EMR中的交班记录具有其他可通过网络访问的电子系统的优点，并且还能以自动化方式纳入病历中已有的信息。虽然引入标准化的、集成在EMR中的交班记录的主要动机是提高患者交接的安全性，但改善医生工作流程的感觉也是这种干预措施带来的一个好处。
