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在新冠疫情高峰期减轻护理文件记录负担

Decreasing the Nursing Documentation Burden During the Covid-19 Surge.

作者信息

Holub Marci, Giegerich Catherine A

出版信息

Nurse Lead. 2023 Feb;21(1):38-41. doi: 10.1016/j.mnl.2022.11.006. Epub 2022 Nov 9.

Abstract

During the Covid-19 pandemic, nurses requested a clean, streamlined, and intuitive view of the adult nursing assessment(s) within the electronic medical record (EMR). We created a more efficient method during a national disaster to reduce duplicative efforts and allow additional time with patients. This project was added as part of the clinically led EMR optimization strategy to eliminate unnecessary EMR assessment data elements in the adult medical, surgical, and critical care areas. This was completed in a 5-month period and decreased 20% of the data points entered by nursing. A total of 433 data points were excluded or relocated to achieve the desired result.

摘要

在新冠疫情期间,护士们要求在电子病历(EMR)中能有一个清晰、简洁且直观的成人护理评估视图。我们在一场全国性灾难期间创建了一种更高效的方法,以减少重复工作,并能有更多时间陪伴患者。该项目作为临床主导的电子病历优化策略的一部分,旨在消除成人医疗、外科和重症监护领域中不必要的电子病历评估数据元素。这项工作在5个月内完成,护理人员输入的数据点减少了20%。总共排除或重新安置了433个数据点,以达到预期效果。

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