Winer Rachel A, Bennett Eleanor, Murillo Illouise, Schuetz-Mueller Jan, Katz Craig L
Stanford Hospital & Clinics, 401 Quarry Road, Room 2206, Stanford, CA, 94305, USA,
Psychiatr Q. 2015 Sep;86(3):373-9. doi: 10.1007/s11126-014-9331-5.
Belize trained psychiatric nurse practitioners (PNPs) in the early 1990s to provide mental health services throughout the country. Despite overwhelming success, the program is limited by lack of monitoring, evaluation, and surveillance. To promote quality assurance, we developed a chart audit tool to monitor mental healthcare delivery compliance for initial psychiatric assessment notes completed by PNPs. After reviewing the Belize Health Information System electronic medical record system, we developed a clinical audit tool to capture 20 essential components for initial assessment clinical notes. The audit tool was then piloted for initial assessment notes completed during July through September of 2013. One hundred and thirty-four initial psychiatric interviews were audited. The average chart score among all PNPs was 9.57, ranging from 3 to 15. Twenty-three charts-or 17.2%-had a score of 14 or higher and met a 70% compliance benchmark goal. Among indicators most frequently omitted included labs ordered and named (15.7%) and psychiatric diagnosis (21.6%). Explicit statement of medications initiated with dose and frequency occurred in 47.0% of charts. Our findings provide direction for training and improvement, such as emphasizing the importance of naming labs ordered, medications and doses prescribed, and psychiatric diagnoses in initial assessment clinical notes. We hope this initial assessment helps enhance mental health delivery compliance by prompting creation of BHIS templates, development of audits tools for revisit follow-up visits, and establishment of corrective actions for low-scoring practitioners. These efforts may serve as a model for implementing quality assurance programming in other low resource settings.
伯利兹在20世纪90年代初培训了精神科执业护士，以便在全国提供心理健康服务。尽管取得了巨大成功，但该项目因缺乏监测、评估和监督而受到限制。为了促进质量保证，我们开发了一种图表审核工具，以监测精神科执业护士完成的初始精神科评估记录中的精神卫生保健提供合规情况。在审查了伯利兹健康信息系统电子病历系统后，我们开发了一种临床审核工具，以获取初始评估临床记录的20个基本组成部分。然后，该审核工具在2013年7月至9月期间完成的初始评估记录中进行了试点。对134次初始精神科访谈进行了审核。所有精神科执业护士的平均图表得分是9.57，范围从3到15。23份图表（即17.2%）得分在14分或更高，达到了70%的合规基准目标。最常被遗漏的指标包括所开实验室检查项目及名称（15.7%）和精神科诊断（21.6%）。47.0%的图表中明确说明了开始使用的药物及其剂量和频率。我们的研究结果为培训和改进提供了方向，例如强调在初始评估临床记录中列出所开实验室检查项目、所开药物及剂量以及精神科诊断的重要性。我们希望这种初始评估通过促使创建伯利兹健康信息系统模板、开发复诊随访审核工具以及为得分较低的执业人员制定纠正措施，有助于提高精神卫生服务的合规性。这些努力可作为在其他资源匮乏地区实施质量保证计划的典范。
