McMurray Josephine, Stolee Paul, Hicks Elisabeth, Elliott Jacobi, Johnson Helen, Byrne Kerry
Wilfrid Laurier University, Waterloo, ON, Canada.
Stud Health Technol Inform. 2013;192:1197.
Maintaining continuity of patient care can be difficult during transitions between care settings, when quality of care and patient safety are at risk. We sought to understand the role of inter-provider documentation and information exchange across successive care settings for complex, older patients. Data were gathered as part of a multi-site ethnographic study that followed 23 older post-surgical hip fracture patients across multiple care transitions. Documentation and information exchange help build a "picture" of complex patients, but care continuity is challenged by late, missing or unnecessary information, duplicated assessments and lack of interoperability of electronic systems. This study demonstrates the importance of appropriate documentation in the transition process, but points to the need for comprehensive system-level solutions which standardize information collection and sharing along the continuum of care.
在不同护理环境之间的过渡阶段，当护理质量和患者安全面临风险时，保持患者护理的连续性可能会很困难。我们试图了解跨连续护理环境的提供者间文档记录和信息交换对于复杂的老年患者所起的作用。数据收集是一项多地点人种学研究的一部分，该研究跟踪了23名接受髋关节骨折手术后的老年患者在多个护理过渡阶段的情况。文档记录和信息交换有助于构建复杂患者的 “全貌”，但护理连续性受到信息延迟、缺失或不必要、重复评估以及电子系统缺乏互操作性的挑战。本研究证明了在过渡过程中进行适当文档记录的重要性，但也指出需要全面的系统级解决方案，以规范整个护理连续过程中的信息收集和共享。
