Kochendorfer Karl M, Morris Laura E, Kruse Robin L, Ge Bin Ge, Mehr David R
Department of Family and Community Medicine, University of Missouri, Columbia, MO 65212, USA.
Fam Med. 2010 May;42(5):343-9.
With limited work hours, efficient rounding and effective hand-offs have become essential. We created a completely electronic medical record (EMR)-generated rounding report for use during pre-rounding, team rounds, and sign-out/hand-offs. We hypothesized that this would reduce workloads.
We used a pre- and post-implementation survey of the residents and faculty members of the Departments of Family and Community Medicine and Internal Medicine.
After 5 months of use, residents and attending physicians reported a daily time savings of 44 minutes. Seventy-six percent of users also agreed that the rounding report improved patient safety. Rounding report users were more satisfied with the rounding process, spent less time updating other lists or documents, and less time pre-rounding. In addition, there were trends toward spending more time with patients, adherence to work-hour rules, increased accuracy of information during sign-out, improved satisfaction, confidence while cross-covering, and decreased clinically relevant errors.
Utilization of well-designed, EMR-generated reports for the use of patient transfer, sign-out, and rounding should become more commonplace considering the improved efficiency, satisfaction, and potential for improved patient care.
由于工作时间有限，高效的查房和有效的交接班变得至关重要。我们创建了一份完全由电子病历（EMR）生成的查房报告，用于预查房、团队查房以及交班/交接过程。我们假设这将减少工作量。
我们对家庭与社区医学系和内科的住院医师和教员进行了实施前和实施后的调查。
使用5个月后，住院医师和主治医师报告每天节省44分钟。76%的用户还认为查房报告提高了患者安全。使用查房报告的用户对查房过程更满意，更新其他列表或文件所花时间更少，预查房时间也更少。此外，还出现了一些趋势，包括与患者相处时间增加、遵守工作时间规定、交班时信息准确性提高、满意度提升、交叉值班时信心增强以及临床相关错误减少。
考虑到效率提高、满意度提升以及改善患者护理的潜力，利用精心设计的、由EMR生成的报告进行患者转接、交班和查房应该变得更加普遍。
