Paediatric, Sitaram Bhartia Institute of Science and Research, New Delhi, India.
Quality, Sitaram Bhartia Institute of Science and Research, New Delhi, India.
BMJ Open Qual. 2022 May;11(Suppl 1). doi: 10.1136/bmjoq-2021-001472.
Audits on record keeping practices at our multidisciplinary hospital revealed unstructured ward-round notes which were dissimilar from each other on aspects of patient information. Written as per the discretion of the rounding physician, the practice compromised team communication and medicolegal safety and risked patient harm. Paediatricians decided to address this concern for their department and proposed to improve the quality of documentation by structuring their notes using subjective, objective, assessment and planning (SOAP) format. On observing only 13% compliance with SOAP use despite education and training to use it, a series of interventions were explored to increase its application.
Brainstorming sessions with the paediatricians provided practical solutions. These were tested one by one using plan-do-study-act cycles to understand their impact. Team feedback was pursued towards the end of each cycle to understand the opinion of each team member.
Interventions included verbal reminders, individual feedback and SOAP acronym display. Each of these were tested singularly and serially. Acronym display proved successful until the arrival of COVID-19, which disrupted its implementation and redirected paediatricians' work priorities. This led to exploration of a new solution, and paediatricians recommended use of visual reminders at the handover site. Quantitative information was analysed to reject or retain the ideas.
Verbal reminders and individual feedback made no difference to SOAP usage. Acronym display improved compliance from 13% to 90% but it fell to 45% during COVID-19. Its replacement with visual reminders during pandemic times reinstated the compliance to a median of 84%.
Selection of a change idea that respected front liner's constraints and suited local work environment proved valuable. Both acronym display and visual reminders served as visual reinforcements towards embracing a note format and proved effective. Perceived benefits from methodically written notes encouraged paediatricians to re-establish simpler measures to retain SOAP application, otherwise disrupted during the COVID-19 pandemic.
我们多学科医院的记录保存实践审计显示，病房巡视记录不规范，在患者信息方面彼此之间存在差异。这些记录是根据查房医生的判断随意书写的，这种做法影响了团队沟通和医疗法律安全，并可能对患者造成伤害。儿科医生决定解决他们部门的这一问题，并提出通过使用主观、客观、评估和计划（SOAP）格式来改进文档的质量。尽管进行了使用 SOAP 的教育和培训，但仅观察到 13%的医生使用 SOAP，因此探索了一系列干预措施来增加其应用。
与儿科医生进行头脑风暴会议提供了切实可行的解决方案。使用计划-执行-研究-行动（PDCA）循环逐个测试这些解决方案，以了解其影响。在每个循环结束时，团队会寻求反馈，以了解每个团队成员的意见。
干预措施包括口头提醒、个人反馈和 SOAP 首字母缩写显示。这些措施单独测试并连续测试。首字母缩写显示在到达 COVID-19 之前一直有效，它扰乱了实施并改变了儿科医生的工作重点。这导致了新解决方案的探索，儿科医生建议在交接班现场使用视觉提醒。对定量信息进行了分析，以拒绝或保留这些想法。
口头提醒和个人反馈对 SOAP 使用没有影响。首字母缩写显示使依从性从 13%提高到 90%，但在 COVID-19 期间降至 45%。在大流行期间用视觉提醒代替它，使依从性恢复到中位数 84%。
选择一个尊重一线人员限制并适合当地工作环境的变革想法是有价值的。首字母缩写显示和视觉提醒都作为接受笔记格式的视觉强化手段，非常有效。从有系统地书写的笔记中获得的好处，鼓励儿科医生重新采取更简单的措施来保留 SOAP 的应用，否则在 COVID-19 大流行期间会受到干扰。
