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护理记录框架(SBAR、SOAP和PIE)在加强临床交接班及患者安全方面的有效性。

Effectiveness of Nursing Documentation Frameworks (SBAR, SOAP, and PIE) in Enhancing Clinical Handoffs and Patient Safety.

作者信息

Hidalgo Tapia Esthela Carolina, León Yosa Joanna, Olalla García María Humbelina, Clavijo Morocho Nube Janeth, Sanmartín Calle Yesenia Alexandra

机构信息

Nursing Education, Universidad de Cuenca, Cuenca, ECU.

Nursing Education, Universidad Estatal de Bolivar, Guaranda, ECU.

出版信息

Cureus. 2025 Aug 13;17(8):e89957. doi: 10.7759/cureus.89957. eCollection 2025 Aug.

Abstract

Constructed communication models, including SBAR (Situation, Background, Assessment, Recommendation), SOAP (Subjective, Objective, Assessment, Plan), and PIE (Problem, Intervention, Evaluation), have become more and more significant in the field of nursing because of improving handoff communication and ensuring patient safety. The purposes of these documentation formats are to achieve consistency in sharing information, keep to a minimum the occurrence of errors, and enhance the concreteness and effectiveness of communication between healthcare professionals. The systematic review was conducted to determine how the SBAR, SOAP, and PIE models can help to enhance the quality of the handoff process, alleviating the number of clinical errors and ensuring the safety of patients in different clinical contexts. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. A comprehensive literature search was performed across PubMed, Web of Science, and the Cochrane Library using a combination of text words and controlled vocabulary. Studies published in English between January 2005 and May 2025, involving registered nurses and nursing staff in hospital or inpatient settings, were included. Only quasi-experimental studies, randomized controlled trials, and mixed-method studies were considered. Risk of bias was assessed using the Cochrane Risk of Bias (RoB) 2.0 for randomized controlled trials and the Risk of Bias In Non-randomized Studies of Interventions (ROBINS-I) for non-randomized studies, and the methodological quality of mixed-method studies was appraised with the Mixed Methods Appraisal Tool (MMAT). Risk of bias figures were visualized using the robvis tool. A total of 15 studies met the inclusion criteria. The quality of the 15 included studies ranged from moderate to high. Findings demonstrated that structured documentation frameworks significantly improve communication clarity, reduce information omissions, enhance documentation accuracy, and lower the incidence of handoff-related errors. SBAR was particularly effective in high-acuity settings, while SOAP and PIE were beneficial in routine care and ongoing patient assessment. Overall, the implementation of structured nursing documentation enhances interdisciplinary collaboration, supports safer transitions of care, and contributes to improved patient outcomes.

摘要

结构化沟通模式,包括SBAR(情况、背景、评估、建议)、SOAP(主观、客观、评估、计划)和PIE(问题、干预、评价),由于改善了交接班沟通并确保患者安全,在护理领域变得越来越重要。这些文档格式的目的是在信息共享方面实现一致性,将错误的发生降至最低,并提高医疗专业人员之间沟通的具体性和有效性。进行了这项系统评价,以确定SBAR、SOAP和PIE模式如何有助于提高交接班过程的质量,减少临床错误数量,并确保不同临床环境下患者的安全。该评价是根据2020年系统评价和Meta分析的首选报告项目(PRISMA)指南进行的。使用文本词和控制词汇的组合,在PubMed、科学网和考科蓝图书馆进行了全面的文献检索。纳入了2005年1月至2025年5月期间以英文发表的、涉及医院或住院环境中的注册护士和护理人员的研究。仅考虑准实验研究、随机对照试验和混合方法研究。对于随机对照试验,使用考科蓝偏倚风险(RoB)2.0评估偏倚风险,对于非随机研究,使用干预性非随机研究中的偏倚风险(ROBINS-I)评估偏倚风险,并使用混合方法评估工具(MMAT)评估混合方法研究的方法学质量。使用robvis工具将偏倚风险数据可视化。共有15项研究符合纳入标准。纳入的15项研究的质量从中等到高不等。研究结果表明,结构化文档框架显著提高了沟通清晰度,减少了信息遗漏,提高了文档准确性,并降低了与交接班相关的错误发生率。SBAR在高急症环境中特别有效,而SOAP和PIE在常规护理和持续的患者评估中有益。总体而言,结构化护理文档的实施增强了跨学科协作,支持更安全的护理转接,并有助于改善患者结局。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/4e27/12431931/dee27a227674/cureus-0017-00000089957-i01.jpg

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