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未雨绸缪:建立全国范围内护理危机文件记录的共识。

Preparing for the Future: Establishing a National Consensus on Nursing Crisis Documentation.

机构信息

Author Affiliations: Texas Tech University Health Sciences Center, Lubbock (Dr Hoelscher); Texas Tech University Health Sciences Center School of Nursing, Lubbock (Dr McBride); and Ascension Health, Leander, TX (Dr Bumpus).

出版信息

Comput Inform Nurs. 2023 Feb 1;41(2):86-93. doi: 10.1097/CIN.0000000000000896.

Abstract

Clinicians across the globe face overwhelming dissatisfaction and burden with electronic health records due to poor usability and the sheer volume of data collection requirements. In the United States, electronic health records are noted to be a principal source of distress, dissatisfaction, and endless workarounds, leading to poor clinician performance and, ultimately, poor patient outcomes. The purpose of this article is to present a detailed review of a 2020 Texas pilot study. The study's focus was the engagement of nursing informatics experts from around the state to gain consensus on nursing documentation's current status and if plans were being developed to modify or decrease documentation, specifically to alleviate burden during a time of crisis. The study consisted of subject matter expert focus groups, a high-level Delphi for instrument development, and the implementation of the statewide instrument to gain consensus. Ultimately, the research team learned that there were gaps in not only what documentation could be removed (either temporarily or permanently) but also what standards dictate the use of crisis documentation (ie, "surge" criteria). The study findings discussed in this article will inform improvement strategies and policy recommendations to increase the value and usability of crisis nursing documentation requirements.

摘要

全球的临床医生都对电子健康记录的可用性差和数据采集要求过高感到不满和负担过重。在美国,电子健康记录被认为是造成痛苦、不满和无尽的工作流程的主要原因,导致临床医生表现不佳,最终导致患者的结果不佳。本文的目的是对 2020 年德克萨斯州的一项试点研究进行详细回顾。该研究的重点是让来自全州的护理信息学专家参与进来,就护理记录的当前状况达成共识,并确定是否正在制定计划来修改或减少文档记录,特别是在危机期间减轻负担。该研究包括主题专家焦点小组、高级德尔菲法进行仪器开发,以及在全州范围内实施仪器以达成共识。最终,研究小组发现,不仅在可以删除(临时或永久)的文档方面存在差距,而且在规范危机文档使用的标准方面也存在差距(例如,“激增”标准)。本文讨论的研究结果将为改进策略和政策建议提供信息,以提高危机护理文档要求的价值和可用性。

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