Appl Clin Inform. 2012 Apr 4;3(2):154-63. doi: 10.4338/ACI-2012-01-RA-0001. Print 2012.
Small numbers of tests with pending results are documented in hospital discharge summaries leading to breakdown in communication and medical errors due to inadequate followup.
Evaluate effect of using a computerized provider order entry (CPOE) system to enforce documentation of tests with pending results into hospital discharge summaries.
We assessed the percent of all tests with pending results and those with actionable results that were documented before (n = 182 discharges) and after (n = 203 discharges) implementing the CPOE-enforcement tool. We also surveyed providers (n = 52) about the enforcement functionality.
Documentation of all tests with pending results improved from 12% (87/701 tests) before to 22% (178/812 tests) (p = 0.02) after implementation. Documentation of tests with eventual actionable results increased from 0% (0/24) to 50% (14/28)(p<0.001). Survey respondents felt the intervention improved quality of summaries, provider communication, and was not time-consuming.
A CPOE tool enforcing documentation of tests with pending results into discharge summaries significantly increased documentation rates, especially of actionable tests. However, gaps in documentation still exist.
医院出院小结中记录了少量待处理结果的检查，导致沟通中断和医疗错误，因为后续跟进不充分。
评估使用计算机化医嘱录入系统（CPOE）强制将待处理结果的检查记录到医院出院小结中的效果。
我们评估了在实施 CPOE 强制工具之前（n=182 出院）和之后（n=203 出院）所有待处理结果和有可操作结果的检查的百分比。我们还对提供者（n=52）进行了关于强制执行功能的调查。
所有待处理结果的检查记录从实施前的 12%（87/701 个测试）提高到实施后的 22%（178/812 个测试）（p=0.02）。有最终可操作结果的检查记录从 0%（0/24）增加到 50%（14/28）（p<0.001）。调查受访者认为干预措施提高了摘要的质量、提供者之间的沟通，并且不会耗费时间。
强制将待处理结果的检查记录到出院小结中的 CPOE 工具显著提高了记录率，特别是可操作检查的记录率。然而，记录仍然存在差距。
