Department of Trauma and Orthopaedics, Southmead Hospital, Bristol, UK.
Department of Trauma and Orthopaedics, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK.
Br J Hosp Med (Lond). 2022 Jun 2;83(6):1-5. doi: 10.12968/hmed.2021.0209. Epub 2022 Jun 10.
BACKGROUND/AIMS: Documentation is key for communicating between members of the multidisciplinary team, allowing for better care, but documentation for spinal patients in the authors' centre was poor.
Every ward round encounter was analysed for six weekends. Data were analysed and presented to the department. A weekend ward round proforma was designed to help improve ward-round documentation. Ward round entries were then re-audited over four weekends to assess the usefulness of the new proforma.
A total of 69 patient encounters were analysed in cycle 1, 58 in cycle 2 and 92 in cycle 3. In cycle 1, 80% of encounters had inadequate documentation. Following introduction of the ward round proforma there was a significant improvement in documentation in six out of fields, which was maintained in four out of seven fields 2 years later.
The authors believe that this improvement may avoid adverse effects on patient care, streamline doctors' time and reduce medicolegal consequences.
背景/目的：文档记录对于多学科团队成员之间的沟通至关重要，可以提供更好的护理，但作者所在中心的脊柱患者的文档记录却很差。
对六个周末的每一次病房查房进行分析。对数据进行分析并提交给科室。设计了一个周末查房表格，以帮助改善查房记录。然后在四个周末重新审核查房记录，以评估新表格的实用性。
在第 1 周期中分析了 69 次患者就诊，在第 2 周期中分析了 58 次，在第 3 周期中分析了 92 次。在第 1 周期中，80%的就诊记录没有充分的文档记录。引入病房查房表格后，有六个领域的文档记录显著改善，两年后仍有四个领域中的七个字段保持了这种改善。
作者认为，这种改进可能避免对患者护理产生不利影响，简化医生的时间，并减少医疗法律后果。
