Teo S, Hanson R, Van Asperen P, Giles H, Fasher B, Davis A M, Kristidis P
Children's Hospital, Camperdown, New South Wales, Australia.
J Paediatr Child Health. 1995 Apr;31(2):130-3. doi: 10.1111/j.1440-1754.1995.tb00761.x.
To improve documentation for children presenting to the Emergency Department (ED) of The Children's Hospital with acute asthma.
In phase I, the documentation process was analysed using a standard total quality management (TQM) approach to identify specific problems leading to poor documentation. Fifty-two medical records of children presenting over a 3 week period were reviewed for nursing and medical documentation. A set of minimum criteria, consistent with the Paediatric Asthma Management Plan, were established for documentation by both medical and nursing staff. Following dissemination and education, compliance with documentation was evaluated and compared to an asthma survey performed in the ED in 1991. In phase II, a specific proforma for medical assessment was developed and 80 medical records of children presenting over a 3 week period were reviewed. Fifty-two (65%) with completed proformas were evaluated. The outcome measure was the documentation rate for minimum criteria established by TQM process.
In phase I, nursing compliance with documentation ranged from 46% for signs of respiratory distress to 83% for a past history of asthma and 100% for pulse rate. Doctors were similarly poor at documenting essential elements such as severity (31%), palpable pulsus paradoxus (29%), the child's usual doctor (46%) and follow-up arrangements (21-56%). In phase II, the documentation of the severity of acute asthma (42%) and of the child's usual doctor (42%) remained poor but there were statistically significant improvements in documentation of interval medications, palpable pulsus paradoxus, respiratory rate, pre-treatment oximetry, education, follow-up arrangements and communication letters.
The process of TQM has proved valuable in improving some aspects of documentation of children presenting to ED with acute asthma. It remains to be shown whether improved documentation will result in improved outcome.
改善儿童医院急诊科急性哮喘患儿的病历记录。
在第一阶段，采用标准的全面质量管理（TQM）方法分析病历记录过程，以确定导致记录不佳的具体问题。回顾了52份在3周内就诊的儿童病历的护理和医疗记录。制定了一套与《儿童哮喘管理计划》一致的医护人员记录最低标准。在进行传播和教育之后，评估了记录的合规情况，并与1991年在急诊科进行的哮喘调查进行了比较。在第二阶段，制定了一份具体的医学评估表格，并回顾了80份在3周内就诊的儿童病历。对其中52份（65%）填写完整表格的病历进行了评估。结果指标是全面质量管理过程确定的最低标准的记录率。
在第一阶段，护理记录的合规率从呼吸窘迫体征的46%到哮喘既往史的83%以及脉搏率的100%不等。医生在记录严重程度（31%）、可触及的奇脉（29%）、患儿的常规医生（46%）和随访安排（21%-56%）等关键要素方面同样表现不佳。在第二阶段，急性哮喘严重程度（42%）和患儿常规医生（42%）的记录仍然较差，但在间歇用药、可触及的奇脉、呼吸频率、治疗前血氧饱和度、教育、随访安排和沟通信件的记录方面有统计学上的显著改善。
全面质量管理过程已证明在改善急诊科急性哮喘患儿病历记录的某些方面具有价值。记录的改善是否会带来更好的治疗结果仍有待观察。
