评估强化基于病房的写作指导计划以改善护理文档：经验教训。
Evaluating an intensive ward-based writing coach programme to improve nursing documentation: lessons learned.
机构信息
School of Nursing and Midwifery, Centre for Applied Nursing Research (Joint Facility of SSWAHS & the University of Western Sydney), College of Health & Science, University of Western Sydney, Sydney, NSW, Australia.
出版信息
Int Nurs Rev. 2012 Sep;59(3):394-401. doi: 10.1111/j.1466-7657.2012.00994.x. Epub 2012 Mar 29.
AIM
This study aimed to develop a ward-based writing coach programme to improve the quality of patient information in nursing documentation.
BACKGROUND
Omissions in the patient information make nursing notes an unreliable source for care planning. Strategies to improve the quality of nursing documentation have been unsuccessful. An education programme, with one-to-one coaching in the clinical environment, was tested.
METHOD
A concurrent mixed methods approach including a pre-post test intervention and control design for the quantitative component combined with a qualitative approach using a focus group (eight nurses) was used. Healthcare records for 87 patients (intervention) (46 pre and 41 post) and 88 patients (control) (51 pre and 37 post) were reviewed using the Nursing and Midwifery Content Audit Tool for quality nursing documentation. Sixteen nurses from two intervention wards participated in an introductory workshop with 2 weeks of coaching. No intervention was given to the control ward.
RESULTS
No significant differences were found between the wards across the 14 criteria representing quality documentation; most criteria were present in 75% or more of the records. Improvements were demonstrated in both the intervention and comparison units. Themes identified from the focus groups included the impact these changes had on nurses and patients, perceived difficulties with nursing documentation, medicolegal aspects and the attributes of an effective writing coach.
CONCLUSION
Writing coaching is a supportive approach to improving nursing documentation. Also, regular auditing prompts nurses to improve nursing documentation. Further research using larger sample sizes can further confirm or refute these findings.
目的
本研究旨在开发一种基于病房的写作指导方案，以提高护理记录中患者信息的质量。
背景
患者信息的遗漏使得护理记录成为护理计划不可靠的依据。已经尝试了多种策略来提高护理记录的质量，但都没有成功。本研究测试了一种教育方案，即在临床环境中进行一对一辅导。
方法
采用了一种同时结合定量和定性方法的混合方法，定量部分采用前后测试干预和对照设计，定性部分采用焦点小组（8 名护士）的方法。使用护理和助产内容审核工具，对 87 名患者（干预组）（46 名前和 41 名后）和 88 名患者（对照组）（51 名前和 37 名后）的医疗记录进行了回顾，以评估护理记录的质量。来自两个干预病房的 16 名护士参加了一个介绍性研讨会，并接受了两周的辅导。对照病房没有接受干预。
结果
在代表质量文件的 14 项标准中，两个病房之间没有发现显著差异；大多数标准都存在于 75%或更多的记录中。干预组和对照组都有改进。焦点小组确定的主题包括这些变化对护士和患者的影响、对护理文件记录的感知困难、医疗法律方面以及有效写作指导者的属性。
结论
写作指导是一种支持性的方法，可以提高护理记录的质量。此外，定期审核可以促使护士提高护理记录的质量。使用更大的样本量进行进一步研究可以进一步证实或反驳这些发现。
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