Al-Mahrouqi Haitham, Oumer Ramadan, Tapper Richard, Roberts Ross
BMJ Qual Improv Rep. 2013 May 17;2(1). doi: 10.1136/bmjquality.u201042.w688. eCollection 2013.
In health care, record keeping of doctor-patient encounters is vital for quality patient care and medico-legal reasons. We audited the documentation of post-acute consultant ward round (PACWR) in our department before and six months after an introduction of a proforma (standard form). The clinical notes of all patients admitted acutely under General Surgery over a period of one week before and one week after the introduction of a proforma were reviewed to note whether time and date, signature, impression and dietary plan were documented after PACWR. The nurses were also surveyed on the day of the PACWR for their certainty regarding the dietary plan of their patients and whether they had to contact the surgical team for clarification. There were 108 and 103 patients eligible for the first and second study periods respectively. After the introduction of the proforma, there was a statistically significant improvement in the documentation of time and date (37% vs. 72%, p-value < 0.01) and impression (40% vs. 61%, p-value < 0.01). Improvement in the documentation of the dietary plan reached statistical significant only when the analysis was restricted to the cases where a proforma was filled out (78 out of 103 patients). Introduction of the proforma had no statistically significant impact on the nurses' certainty regarding their patients' dietary plan and the number of times they had to contact the surgical teams. In conclusion, PACWR proforma improves overall documentation. This will help in avoiding adverse effects on patient care and medico-legal ramifications.
在医疗保健领域，出于优质患者护理和医疗法律方面的原因，记录医患诊疗过程至关重要。我们在引入一种表格（标准表格）之前和之后六个月，对本部门急性后咨询病房查房（PACWR）的文档进行了审核。回顾了在引入表格之前一周和之后一周内所有普通外科急性入院患者的临床记录，以查看在PACWR之后是否记录了时间和日期、签名、诊断意见及饮食计划。还在PACWR当天对护士进行了调查，询问他们对患者饮食计划的确定程度以及是否需要联系外科团队进行澄清。分别有108名和103名患者符合第一个和第二个研究阶段的条件。引入表格后，时间和日期的记录（37%对72%，p值<0.01）以及诊断意见的记录（40%对61%，p值<0.01）有统计学上的显著改善。仅当分析仅限于填写了表格的病例（103名患者中的78名）时，饮食计划记录的改善才达到统计学显著水平。引入表格对护士对患者饮食计划的确定程度以及他们联系外科团队的次数没有统计学上的显著影响。总之，PACWR表格改善了整体文档记录。这将有助于避免对患者护理产生不利影响以及医疗法律后果。
