Kentley Jonathan, Fox Amy, Taylor Sophia, Hassan Yahya, Filipek Alicja
Barts Health NHS Foundation Trust, UK.
BMJ Qual Improv Rep. 2016 Mar 3;5(1). doi: 10.1136/bmjquality.u210642.w4280. eCollection 2016.
At our institution, a large tertiary referral centre for vascular surgery, patients are often admitted directly to the ward and clerked by foundation year one (FY1) doctors. We found that these clerkings frequently fell short of national record keeping standards, potentially leading to an increased risk for patients during their hospital stay. In addition, we found that junior doctors did not feel confident in clerking vascular surgery patients. A literature review found that high quality clerkings were strongly linked to improved patient safety, and that the use of a pro forma was one method to improve compliance with documentation guidelines. We devised a clerking pro forma based on national guidelines and introduced it to the department. We found that the use of a pro forma significantly improved documentation standards across a number of domains, including patient demographics, presenting complaint, and family and social histories (p <0.05). Examinations were significantly more comprehensive, with cardiac and vascular examination as well as peripheral pulses documented (p <0.05). In conclusion, we found that using a pro forma helped to aid junior doctors in clerking new patients, and significantly improved the quality of their history and examinations. This leads to a potential positive impact on patient safety during their inpatient stay, and should be rolled out more widely across the hospital.
在我们医院，一家大型血管外科三级转诊中心，患者通常直接被收治入院并由一年级住院医生（FY1）进行病历记录。我们发现这些病历记录常常达不到国家记录保存标准，这可能会增加患者住院期间的风险。此外，我们发现初级医生对血管外科患者的病历记录缺乏信心。一项文献综述发现，高质量的病历记录与提高患者安全密切相关，而使用模板是提高文档记录指南依从性的一种方法。我们根据国家指南设计了一份病历记录模板并引入科室。我们发现，使用模板在多个领域显著提高了文档记录标准，包括患者人口统计学信息、就诊主诉以及家庭和社会病史（p<0.05）。检查也明显更加全面，记录了心脏和血管检查以及外周脉搏情况（p<0.05）。总之，我们发现使用模板有助于帮助初级医生为新患者进行病历记录，并显著提高他们病史和检查的质量。这可能会对患者住院期间的安全产生积极影响，应在全院更广泛地推广。
