Wilbanks Bryan A, Geisz-Everson Marjorie, Boust Rebecca R
Author Affiliations: The University of Alabama at Birmingham School of Nursing (Dr Wilbanks); The University of Southern Mississippi Nurse Anesthesia Program, Hattiesburg (Dr Geisz-Everson); and Saint Luke's Hospital, Kansas City, Missouri (Ms Boust).
Comput Inform Nurs. 2016 Sep;34(9):406-12. doi: 10.1097/CIN.0000000000000270.
Clinical documentation is a critical tool in supporting care provided to patients. Sound documentation provides a picture of clinical events that can be used to improve patient care. However, many other uses for clinical documentation are equally important. Such documentation informs clinical decision support tools, creates a legal record of patient care, assists in financial reimbursement of services, and serves as a repository for secondary data analysis. Conversely, poor documentation can impair patient safety and increase malpractice risk exposure by reflecting poor or inaccurate information that ultimately may guide patient care decisions.Through an examination of anesthesia-related closed claims, a descriptive qualitative study emerged, which explored the antecedents and consequences of documentation quality in the claims reviewed. A secondary data analysis utilized a database generated by the American Association of Nurse Anesthetists Foundation closed claim review team. Four major themes emerged from the analysis. Themes 1, 2, and 4 primarily describe how poor documentation quality can have negative consequences for clinicians. The third theme primarily describes how poor documentation quality that can negatively affect patient safety.
临床文档是支持为患者提供护理的关键工具。完善的文档记录描绘了临床事件的情况，可用于改善患者护理。然而，临床文档的许多其他用途同样重要。此类文档为临床决策支持工具提供信息，创建患者护理的法律记录，协助服务的财务报销，并作为二次数据分析的存储库。相反，记录不佳可能会损害患者安全，并通过反映最终可能指导患者护理决策的不良或不准确信息而增加医疗事故风险暴露。通过对与麻醉相关的已结案索赔进行审查，开展了一项描述性定性研究，探讨了所审查索赔中文档质量的前因后果。二次数据分析利用了美国麻醉护士协会基金会已结案索赔审查团队生成的数据库。分析得出了四个主要主题。主题1、2和4主要描述了文档质量差如何对临床医生产生负面影响。第三个主题主要描述了文档质量差如何对患者安全产生负面影响。
