在一个综合医疗体系内，不同医疗机构的护理文件变化。

Nursing Documentation Variation Across Different Medical Facilities Within an Integrated Healthcare System.

机构信息

Author Affiliations: College of Nursing, The Catholic University of Korea, Seoul, Republic of Korea (Dr Kang); Division of General Internal Medicine and Primary Care, Brigham & Women's Hospital, Boston, MA (Mr Chang, Dr Schnock, Mr Garcia, and Dr Dykes); Harvard Medical School, Boston, MA (Dr Schnock, and Dr Dykes); School of Nursing (Dr Rossetti, Mr Knaplund, and Dr Cato) and Department of Biomedical Informatics (Dr Rossetti), Columbia University, New York, NY; Massachusetts General Hospital, Boston, MA (Ms Whalen); University of Massachusetts-Dartmouth, College of Nursing and Health Sciences, Department of Community Nursing, North Dartmouth, MA (Dr Gesner).

出版信息

Comput Inform Nurs. 2021 May 3;39(12):845-850. doi: 10.1097/CIN.0000000000000736.

DOI:10.1097/CIN.0000000000000736

PMID:33935196

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC8720562/

Abstract

The purpose of this study was to demonstrate nursing documentation variation based on electronic health record design and its relationship with different levels of care by reviewing how various flowsheet measures, within the same electronic health record across an integrated healthcare system, are documented in different types of medical facilities. Flowsheet data with information on patients who were admitted to academic medical centers, community hospitals, and rehabilitation centers were used to calculate the frequency of flowsheet entries documented. We then compared the distinct flowsheet measures documented in five flowsheet templates across the different facilities. We observed that each type of healthcare facility appeared to have distinct clinical care foci and flowsheet measures documented differed within the same template based on facility type. Designing flowsheets tailored to study settings can meet the needs of end users and increase documentation efficiency by reducing time spent on unrelated flowsheet measures. Furthermore, this process can save nurses time for direct patient care.

摘要

本研究旨在通过考察同一电子病历系统内不同类型的医疗设施中各种流程表测量值的记录方式，展示基于电子病历设计的护理记录差异及其与不同护理水平的关系。利用包含在学术医疗中心、社区医院和康复中心的入院患者信息的流程表数据，计算流程表记录的条目频率。然后，我们比较了不同设施中五个流程表模板中记录的不同流程表测量值。我们发现，每种类型的医疗设施似乎都有独特的临床护理重点，并且基于设施类型，同一模板中记录的流程表测量值也有所不同。根据研究环境定制流程表可以满足最终用户的需求，并通过减少花在无关流程表测量值上的时间来提高文档记录效率。此外，这个过程可以为护士节省直接护理患者的时间。