Regional Hospital Mullingar, Longford Road, Robinstown, Mullingar, Co Westmeath, Republic of Ireland.
Ir J Med Sci. 2021 Nov;190(4):1547-1551. doi: 10.1007/s11845-020-02475-1. Epub 2021 Jan 19.
Inadequate medical documentation has been associated with a higher rate of adverse events and may have medicolegal consequences. An accurate admission note is critical as it is frequently referred to during inpatient stay, particularly when the patient is acutely unwell and during handover of care.
We set out to implement a surgical admission proforma and evaluate its impact on the quality of acute surgical admission notes.
A standardised, structured admission proforma for use with all emergency general surgery patients in a busy model 3 hospital was designed and implemented. Previously, all admission notes were performed freehand. The quality and completeness of admission notes was evaluated both before and after implementation of the proforma over two separate 4-week periods by assessing documentation across 19 criteria.
Two hundred and fifty-one admission notes before proforma implementation and 273 admission notes after implementation were assessed. Proforma uptake was 97%. Documentation improved in all 19 criteria, with statistical significance achieved in 17 of these. These include past medical history, medication lists, allergy status, physical examination findings, blood results, vital signs and management plan. The proforma showed evidence of improved communication with both nursing staff and senior colleagues.
The surgical admission proforma has significantly improved the quality and completeness of admission documentation, ensuring improved patient safety and efficiency of care. Structured admission proformas have a positive impact on patient outcomes, doctors' performance, hospital efficiency, communication and audit quality control, thus providing multiple clear benefits in comparison to freehand admission notes.
不充分的医疗记录与更高的不良事件发生率有关，并且可能具有法律后果。准确的入院记录至关重要，因为它在住院期间经常被引用，尤其是当患者病情急性恶化和护理交接时。
我们旨在实施外科入院表单，并评估其对急性外科入院记录质量的影响。
设计并实施了一种标准化、结构化的入院表单，用于繁忙的 3 级模式医院的所有急诊普通外科患者。在此之前，所有入院记录都是手写的。通过评估 19 项标准的记录，在表单实施前后的两个独立的 4 周内评估入院记录的质量和完整性。
在实施表单之前评估了 251 份入院记录，在实施表单之后评估了 273 份入院记录。表单的采用率为 97%。所有 19 项标准的记录都有所改善，其中 17 项具有统计学意义。这些包括既往病史、药物清单、过敏状态、体格检查结果、血液检查结果、生命体征和管理计划。该表单还证明了它与护理人员和高级同事之间的沟通得到了改善。
外科入院表单显著提高了入院记录的质量和完整性，确保了患者的安全和护理效率。结构化入院表单对患者的预后、医生的表现、医院的效率、沟通和审核质量控制都有积极的影响，与手写入院记录相比具有多重明显的优势。
