Sockolow Paulina, Wojciechowicz Christine, Holmberg Annika, Bass Ellen J, Potashnik Sheryl, Yang Yushi, Bowles Kathryn H
College of Nursing and Health Professions, Drexel University, Philadelphia, PA USA.
University of Pennsylvania School of Nursing, Philadelphia, PA USA.
Stud Health Technol Inform. 2018;250:164-168.
Effective communication between clinicians across care settings is fundamental for continuity of care and decreased risk of errors. The home care admission often starts without important information needed for formulation of the plan of care. We conducted a mixed methods analysis to investigate home care admission information from two perspectives: qualitative information regarding information nurses reported they needed during an admission, and quantitative information regarding information actually available. We mapped both data sets to an international specification for transitions in care information, the Continuity of Care Document (CCD). The information that homecare nurses said they needed mapped sufficiently (90%) to the CCD. Regarding available information: no observation had all the CCD information present; CCD information was missing in varying amounts across the admission documents. Nurses searching among pages of documentation for information which may not be present is inefficient and introduces patient safety concerns of increased risk for errors.
不同医疗环境下临床医生之间的有效沟通对于持续护理和降低错误风险至关重要。家庭护理入院时往往没有制定护理计划所需的重要信息。我们进行了一项混合方法分析，从两个角度调查家庭护理入院信息：一是护士报告的入院期间所需信息的定性信息，二是实际可用信息的定量信息。我们将这两个数据集映射到护理信息过渡的国际规范——护理连续性文件（CCD）。家庭护理护士表示他们所需的信息有足够比例（90%）映射到了CCD。关于可用信息：没有一份观察记录包含所有的CCD信息；不同入院文件中CCD信息缺失的数量各不相同。护士在大量文件页面中查找可能不存在的信息效率低下，并且带来了错误风险增加的患者安全问题。
