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一项关于牧师干预措施与结果的电子病历回顾:一个质量改进与文档实践强化项目。

An e-Chart Review of Chaplains' Interventions and Outcomes: A Quality Improvement and Documentation Practice Enhancement Project.

作者信息

Stang Vivian B

机构信息

The Ottawa Hospital, Ottawa, ON, Canada.

出版信息

J Pastoral Care Counsel. 2017 Sep;71(3):183-191. doi: 10.1177/1542305017703127.

Abstract

In Canada, the spiritual care landscape in health care settings is becoming more regulated and standardized documentation is part of this rigorous environment. Staff chaplains at The Ottawa Hospital participated in a Quality Improvement project that aimed to advance patient-centered care through better charting practices. A sample of 104 spiritual-care assessments that had been posted on the patient electronic health record was examined. This chart review focused on chaplains' activities that were reported as interventions as well as chaplain-reported outcomes for the patient. These interventions and outcomes were coded into discreet categories in order to get a better sense of the activities and the impact of their work. The chaplains' electronic charting content and practices were evaluated. Chaplains found that the Quality Improvement process was beneficial as they updated their electronic templates in order to meet the new reporting requirements of the College of Registered Psychotherapists of Ontario.

摘要

在加拿大,医疗保健机构中的精神护理领域正受到越来越多的监管,标准化文档是这一严格环境的一部分。渥太华医院的神职人员参与了一个质量改进项目,该项目旨在通过更好的记录做法推进以患者为中心的护理。检查了104份已录入患者电子健康记录的精神护理评估样本。此次病历审查聚焦于神职人员报告为干预措施的活动以及神职人员报告的患者结局。这些干预措施和结局被编码为不同类别,以便更好地了解这些活动及其工作的影响。对神职人员的电子病历记录内容和做法进行了评估。神职人员发现,质量改进过程是有益的,因为他们更新了电子模板,以满足安大略省注册心理治疗师学院的新报告要求。

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