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医师交班记录中团队检查表的分析

An analysis of team checklists in physician signout notes.

作者信息

Stein Daniel M, Vawdrey David K, Stetson Peter D, Bakken Suzanne

机构信息

Columbia University, New York, NY.

出版信息

AMIA Annu Symp Proc. 2010 Nov 13;2010:767-71.

Abstract

Teams of physicians in the hospital collaboratively maintain checklists in informal "signout" documents to help organize, manage, and hand off critical patient-based tasks. We created an application within our commercial EHR that supports basic management of these checklists at two urban, academic medical centers. We collected and analyzed over 400,000 checklist tasks created in the application. We calculated the frequencies of terms and term-combinations (n-grams) in these lists, and compared these data with a previously described clinical task model. Our findings provide evidence for the generalizability of the original clinical task model, and provide the foundation for a more sophisticated physician checklist utility. This could contribute to improved efficiency and safety in patient care.

摘要

医院的医生团队在非正式的“交接班”文件中协同维护清单,以帮助组织、管理和交接基于患者的关键任务。我们在商用电子健康记录(EHR)中创建了一个应用程序,该程序支持在两个城市学术医疗中心对这些清单进行基本管理。我们收集并分析了该应用程序中创建的40多万个清单任务。我们计算了这些清单中术语和术语组合(n元语法)的出现频率,并将这些数据与先前描述的临床任务模型进行了比较。我们的研究结果为原始临床任务模型的通用性提供了证据,并为更复杂的医生清单实用程序奠定了基础。这有助于提高患者护理的效率和安全性。

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