特定诊断计划模板对入院记录书写时间的影响:一项质量改进计划。

Journal of graduate medical education Pub Date : 2024-10-01 Epub Date: 2024-10-15 DOI:10.4300/JGME-D-24-00087.1
Zachary Rumlow, Yahya Almodallal, M Bridget Zimmerman, Rebecca Miner, Rachel Asbury, Lindsey A Knake, Anna Schmitz
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引用次数: 0

摘要

背景 有关减轻住院医师文档记录负担的策略效果的客观研究有限。目的 为住院患者入院记录中的护理计划部分开发并实施特定诊断模板,以减少记录时间。方法 2022 年 9 月 23 日,研究作者编写了 12 个入院记录护理计划部分的模板,经主治医生审核后通过电子病历(EHR)与住院医生共享。研究人员收集了电子病历审计日志数据,以检查入院记录的撰写时间,并通过匿名调查对住院医生的可接受性进行反馈。可行性措施包括时间投入、使用电子病历的经验和住院医师培训。结果 在 2021 年 7 月 1 日至 2023 年 6 月 30 日期间,62 名儿科住院医师共撰写了 9840 份入院记录。557 份入院记录中使用了模板。使用模板后,入院记录所花费的平均总时间从干预前的 97.9 分钟减少到干预后的 71.0 分钟;调整后减少了 23%(95% CI 16%-30%;PC 结论 在入院记录的护理计划部分使用模板可减少住院医师撰写入院记录的时间。
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The Impact of Diagnosis-Specific Plan Templates on Admission Note Writing Time: A Quality Improvement Initiative.

Background There are limited objective studies regarding the effectiveness of strategies to alleviate the documentation burden on resident physicians. Objective To develop and implement diagnosis-specific templates for the plan of care section of inpatient admission notes, aiming to reduce documentation time. Methods Twelve templates for the plan of care section of admission notes were written by the study authors, reviewed by attending physicians, and shared with the residents through the electronic health record (EHR) on September 23, 2022. EHR audit log data were collected to examine admission note writing times, supplemented by resident feedback on acceptability via an anonymous survey. Feasibility measures included time investment, experience with the EHR, and resident training. Results Between July 1, 2021 and June 30, 2023, 62 pediatric residents contributed 9840 admission notes. The templates were used in 557 admission notes. The mean total time spent on an admission note decreased from 97.9 minutes pre-intervention to 71.0 minutes post-intervention with the use of a template; an adjusted reduction of 23% (95% CI 16%-30%; P<.001). The mean attending time spent editing an admission note was unchanged. The survey results underscored wide acceptability of the templates among the residents. Feasibility data showed that the project required minimal time investment from the health care informatics team and minimal resident training. Conclusions Using templates in the care plan section of admission notes reduces the time residents spend writing admission notes.

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来源期刊
Journal of graduate medical education
Journal of graduate medical education Medicine-Medicine (all)
CiteScore
3.20
自引率
0.00%
发文量
248
期刊介绍: - Be the leading peer-reviewed journal in graduate medical education; - Promote scholarship and enhance the quality of research in the field; - Disseminate evidence-based approaches for teaching, assessment, and improving the learning environment; and - Generate new knowledge that enhances graduates'' ability to provide high-quality, cost-effective care.
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