根据葡萄牙物理治疗师协会的实践标准,对在大里斯本地区公立医院重症监护病房工作的物理治疗师的记录进行审计

M.aJ. Pires, I. Souza-Guerra, A. Lopes
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引用次数: 2

摘要

目的:检查在里斯本大都会区公立医院重症监护病房(ICU)工作的物理治疗师的记录是否按照葡萄牙物理治疗师协会(PAP)制定的执业指南进行。方法根据葡萄牙物理治疗师协会已经采用的患者记录审计收集数据,构建了一艘审计船的仪器。该工具有10个评估标准,共48个项目。还拟订了一份18项标准的调查表。经过测试和验证后,将其应用于六家医院,在那里可以收集到80份记录和11份问卷,这代表了物理治疗师的总数。结果经验证,36.4%的记录数据符合所建立的全面质量模式。我们三家医院获得的最高值与文件标准有关。其余部分在分析标准中得到。在安全标准方面,所有医院的正面回答率均为0%。至于记录的重要性,7人(63,6%)认为它非常重要,大多数,5人(45,5%)认为它影响跨学科团队的表现。8人(72.7%)认为执行指导方针对记录非常重要,9人(81.8%)认为听觉对记录很重要。至于向物理治疗师提供特定的队形,大多数(5人)(45,5%)认为有必要。结论通过在记录审核员船中获得36.4%的符合性值,我们可以验证它比期望的要差得多,因为总质量(100%)是设想的。该审核员主要关注记录的质量,较少关注物理治疗师提供的护理。除了有助于持续的专业发展外,它们还可以促进改进新审计船的结果,这应该是为了完成审计船的周期而进行的。
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Auditoría a los registros de los fisioterapeutas que trabajan en la Unidad de Cuidados Intensivos de los hospitales públicos del área metropolitana de Lisboa, de acuerdo con los Patrones de Práctica de la Asociación Portuguesa de Fisioterapeutas

Goal

To check if the records of the physiotherapists, who work in the Intensive Care Units (ICU) of the Public Hospitals, in the metropolitan district of Lisbon, are made according to the guidelines of practice set by the Portuguese Association of Physiotherapists (PAP).

Methodology

An instrument of auditor ship was constructed based on the Patient Record Audit Collection Data, already adapted by the Portuguese Association of Physiotherapists. This instrument has 10 criteria to be evaluated and 48 items in total.

A questionnaire of 18 criteria was elaborated on as well. Following their testing and validation, they were applied to six hospitals, where it has been possible to gather 80 records and 11 questionnaires, which represent the totality of physiotherapists.

Results

It was verified that 36,4 % of the collected records data were in conformity with the established Total Quality patterns. The highest values obtained in three out off our hospitals were linked with the documentation criteria. The remainder was obtained in the analysis criteria. Related to the security criteria, 0 % of positive answers were obtained in all hospitals. As to the importance of the record, seven (63,6 %) consider it very important and the majority, five (45,5 %), consider it influences the performance of the interdisciplinary team. Eight (72,7%), consider the implementation of guidelines for the record very important, and nine (81,8 %), consider the auditory to the records important. As to providing physiotherapists with specific formation, the majority, five (45,5 %), finds it necessary.

Conclusions

By obtaining in the record’s auditor ship a conformity value of 36,4% we could verify it is much inferior than what could be desired, since the Total Quality (100 %) was the one envisaged. This auditor ship primarily focused on the quality of the records, and less on the care given by physiotherapists. In addition to contributing to the continuous professional development, they could facilitate an improvement on the results of a new auditor ship, which should take place in order to complete the cycle of auditor ship.

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