Sullivan James Andy, Gregory James R, Wiley Kevin F, Parris Deborah, Stoner Julie
Departments of Orthopedic Surgery.
The Children's Hospital at OU Medical Center, Oklahoma City, OK.
J Pediatr Orthop. 2019 Nov/Dec;39(10):e777-e781. doi: 10.1097/BPO.0000000000001372.
Supracondylar fractures of the humerus (SCH) are the most common fractures about the elbow in children that require operative stabilization. Considering the possible complications involved including nerve deficit and compartment syndrome, documentation is crucial to good patient care. It also is of prime importance for justification or defense of our care should this arise. One of the common concerns in transition from written documentation to an electronic medical record (EMR) is availability of proper documentation. We sought to develop an established EMR protocol to streamline and improve proper care and documentation for SCH fractures. This was in response to poor documentation in an initial retrospective evaluation.
Documentation before and after the implementation of a clinical pathway were compared. A retrospective chart review was used to collect documentation information before the implementation of the clinical pathway and a prospective study design was used to collect information after the implementation of the clinical pathway. Proportions of preclinical and postclinical pathway documentation were compared before and after the implementation of the clinical pathway using a χ test, or the Fisher exact test for measures in which at least 20% of the expected frequencies were <5. A 2-sided 0.05 α level was used to define statistical significance.
We saw an improvement in documentation after implementation of the clinical pathway, with statistically significant differences in nursing preoperative, physician preoperative, and physician postoperative. Nursing postanesthesia care unit, nursing postoperative, and physician clinic follow-up trended toward improvement but did not meet statistical significance. Although we did see improvement, we still did not meet ideal 100% documentation in all categories.
Documentation is crucial to good medical care and legal defense should any arise. The implementation of a clinical pathway demonstrated significant improvement by physicians and nurses. Although overall improvement was obtained, there were areas associated with EMR identified that still require further improvement.
Level III.
肱骨髁上骨折（SCH）是儿童肘部最常见的骨折，需要手术稳定治疗。考虑到可能出现的并发症，包括神经功能缺损和骨筋膜室综合征，记录对于良好的患者护理至关重要。如果出现这种情况，这对于我们护理的合理性或辩护也至关重要。从书面记录过渡到电子病历（EMR）时的一个常见问题是能否获得适当的记录。我们试图制定一个既定的EMR方案，以简化和改善对SCH骨折的适当护理和记录。这是对最初回顾性评估中记录不佳的回应。
比较临床路径实施前后的记录情况。采用回顾性图表审查收集临床路径实施前的记录信息，并采用前瞻性研究设计收集临床路径实施后的信息。使用χ检验或Fisher精确检验比较临床路径实施前后临床路径前和临床路径后记录的比例，对于预期频率至少20%<5的测量采用该检验。使用双侧0.05的α水平定义统计学显著性。
临床路径实施后记录有所改善，护理术前、医生术前和医生术后存在统计学显著差异。麻醉后护理单元护理、术后护理和医生门诊随访有改善趋势，但未达到统计学显著性。尽管我们确实看到了改善，但我们在所有类别中仍未达到理想的100%记录。
记录对于良好的医疗护理和可能出现的法律辩护至关重要。临床路径的实施显示医生和护士有显著改善。虽然总体上有所改善，但确定的与EMR相关的领域仍需要进一步改进。
三级。
