Currie Jay D, Doucette William R, Kuhle Julie, Sobotka Jenelle, Miller William A, McDonough Randal P, Tice Angela L
J Am Pharm Assoc (Wash). 2003 Jan;43(1):41-9. doi: 10.1331/10865800360467033.
OBJECTIVES To develop guidelines for the documentation elements that need to be included in any record of pharmacist-provided care to allow the quality of the care to be assessed and to describe the use of these guidelines to improve the quality of pharmacist documentation. DESIGN An initial list of 85 potential documentation elements, developed through a review of the literature, was validated by a group of pharmacy practitioners. Then, through three rounds of a Delphi process and a group meeting, a panel of experts reached consensus on a refined list of 27 documentation data elements. RESULTS The documentation elements were formatted into a one-page Tool for Evaluation of Documentation (TED). The TED is a checklist for assessing the completeness of the documentation of pharmacist-provided care. CONCLUSION The TED and the consensus-building methodology used in the development of this tool can serve as cornerstones of a quality assessment process for documentation of pharmacist-provided care, enable further assessment of the quality of care, and, ultimately, be used to measure the impact of pharmacist-provided care on patient outcomes. Our results should provide guidance both to pharmacists providing care and to organizations that assess the quality of that care.
目的 制定指南，明确在药师提供的护理记录中应包含的记录要素，以便评估护理质量，并描述如何使用这些指南来提高药师记录的质量。设计 通过文献回顾制定了包含85个潜在记录要素的初始清单，并由一组药学从业者进行了验证。然后，通过三轮德尔菲法和一次小组会议，专家小组就27个记录数据要素的精炼清单达成了共识。结果 将记录要素整理成一页纸的护理记录评估工具（TED）。TED是一个用于评估药师提供护理记录完整性的清单。结论 TED以及开发此工具所采用的共识建立方法可作为药师提供护理记录质量评估过程的基石，有助于进一步评估护理质量，并最终用于衡量药师提供的护理对患者结局的影响。我们的结果应为提供护理的药师以及评估该护理质量的组织提供指导。
