Xin Piao, Brian H Imdieke, Samantha A Sommerness, Deepti Pandita
{"title":"循证术前评估文件模板可改善围术期沟通。","authors":"Xin Piao, Brian H Imdieke, Samantha A Sommerness, Deepti Pandita","doi":"10.1055/s-0044-1779021","DOIUrl":null,"url":null,"abstract":"<p><strong>Objectives: </strong>The number of surgeries performed in the United States has increased over the past two decades, with a shift to the ambulatory setting. Perioperative complications and mortality pose significant health care burdens. Inadequate preoperative assessment and documentation contribute to communication failure and poor patient outcomes. The aim of this quality improvement project was to design and implement a preoperative evaluation documentation template that not only improved communication during the perioperative pathway but also enhanced the overall user experience.</p><p><strong>Methods: </strong>We implemented a revamped evidence-based documentation template in the electronic medical records of a health care organization across three internal medicine clinics on the downtown campus and seven satellite family medicine clinics. A pre- and postintervention design was used to assess the template utilization rate and clinician satisfaction.</p><p><strong>Results: </strong>The preoperative template utilization rate increased from 51.2% at baseline to 66.5% after the revamped template \"went live\" (<i>p</i> < 0.001). Clinician satisfaction with the preoperative documentation template also significantly increased (30.6 vs. 80.0%, <i>p</i> < 0.001).</p><p><strong>Conclusion: </strong>Adopting a user-friendly, evidence-based documentation template can enhance the standardization of preoperative evaluation documentation and reduce the documentation burden.</p>","PeriodicalId":48956,"journal":{"name":"Applied Clinical Informatics","volume":null,"pages":null},"PeriodicalIF":2.1000,"publicationDate":"2024-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10866639/pdf/","citationCount":"0","resultStr":"{\"title\":\"An Evidence-based Preoperative Evaluation Documentation Template Improves Perioperative Communication.\",\"authors\":\"Xin Piao, Brian H Imdieke, Samantha A Sommerness, Deepti Pandita\",\"doi\":\"10.1055/s-0044-1779021\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p><strong>Objectives: </strong>The number of surgeries performed in the United States has increased over the past two decades, with a shift to the ambulatory setting. Perioperative complications and mortality pose significant health care burdens. Inadequate preoperative assessment and documentation contribute to communication failure and poor patient outcomes. The aim of this quality improvement project was to design and implement a preoperative evaluation documentation template that not only improved communication during the perioperative pathway but also enhanced the overall user experience.</p><p><strong>Methods: </strong>We implemented a revamped evidence-based documentation template in the electronic medical records of a health care organization across three internal medicine clinics on the downtown campus and seven satellite family medicine clinics. A pre- and postintervention design was used to assess the template utilization rate and clinician satisfaction.</p><p><strong>Results: </strong>The preoperative template utilization rate increased from 51.2% at baseline to 66.5% after the revamped template \\\"went live\\\" (<i>p</i> < 0.001). Clinician satisfaction with the preoperative documentation template also significantly increased (30.6 vs. 80.0%, <i>p</i> < 0.001).</p><p><strong>Conclusion: </strong>Adopting a user-friendly, evidence-based documentation template can enhance the standardization of preoperative evaluation documentation and reduce the documentation burden.</p>\",\"PeriodicalId\":48956,\"journal\":{\"name\":\"Applied Clinical Informatics\",\"volume\":null,\"pages\":null},\"PeriodicalIF\":2.1000,\"publicationDate\":\"2024-01-01\",\"publicationTypes\":\"Journal Article\",\"fieldsOfStudy\":null,\"isOpenAccess\":false,\"openAccessPdf\":\"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10866639/pdf/\",\"citationCount\":\"0\",\"resultStr\":null,\"platform\":\"Semanticscholar\",\"paperid\":null,\"PeriodicalName\":\"Applied Clinical Informatics\",\"FirstCategoryId\":\"3\",\"ListUrlMain\":\"https://doi.org/10.1055/s-0044-1779021\",\"RegionNum\":2,\"RegionCategory\":\"医学\",\"ArticlePicture\":[],\"TitleCN\":null,\"AbstractTextCN\":null,\"PMCID\":null,\"EPubDate\":\"2024/2/14 0:00:00\",\"PubModel\":\"Epub\",\"JCR\":\"Q4\",\"JCRName\":\"MEDICAL INFORMATICS\",\"Score\":null,\"Total\":0}","platform":"Semanticscholar","paperid":null,"PeriodicalName":"Applied Clinical Informatics","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.1055/s-0044-1779021","RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"2024/2/14 0:00:00","PubModel":"Epub","JCR":"Q4","JCRName":"MEDICAL INFORMATICS","Score":null,"Total":0}
引用次数: 0
摘要
目的:过去二十年来,美国的外科手术数量不断增加,并向非住院治疗转变。围手术期并发症和死亡率给医疗保健带来了巨大负担。不充分的术前评估和记录会导致沟通失败和不良的患者预后。本质量改进项目旨在设计并实施一种术前评估文件模板,它不仅能改善围手术期的沟通,还能提高用户的整体体验:方法:我们在一家医疗机构的电子病历中实施了一个经过改进的循证文档模板,该模板适用于市中心校园的三个内科诊所和七个卫星家庭医学诊所。我们采用干预前和干预后的设计来评估模板的使用率和临床医生的满意度:结果:术前模板使用率从基线时的 51.2% 提高到改版模板 "上线 "后的 66.5%(p p 结论:采用用户友好型循证医学指南,可提高临床医生的满意度:采用用户友好型循证文档模板可加强术前评估文档的标准化并减轻文档负担。
An Evidence-based Preoperative Evaluation Documentation Template Improves Perioperative Communication.
Objectives: The number of surgeries performed in the United States has increased over the past two decades, with a shift to the ambulatory setting. Perioperative complications and mortality pose significant health care burdens. Inadequate preoperative assessment and documentation contribute to communication failure and poor patient outcomes. The aim of this quality improvement project was to design and implement a preoperative evaluation documentation template that not only improved communication during the perioperative pathway but also enhanced the overall user experience.
Methods: We implemented a revamped evidence-based documentation template in the electronic medical records of a health care organization across three internal medicine clinics on the downtown campus and seven satellite family medicine clinics. A pre- and postintervention design was used to assess the template utilization rate and clinician satisfaction.
Results: The preoperative template utilization rate increased from 51.2% at baseline to 66.5% after the revamped template "went live" (p < 0.001). Clinician satisfaction with the preoperative documentation template also significantly increased (30.6 vs. 80.0%, p < 0.001).
Conclusion: Adopting a user-friendly, evidence-based documentation template can enhance the standardization of preoperative evaluation documentation and reduce the documentation burden.
期刊介绍:
ACI is the third Schattauer journal dealing with biomedical and health informatics. It perfectly complements our other journals Öffnet internen Link im aktuellen FensterMethods of Information in Medicine and the Öffnet internen Link im aktuellen FensterYearbook of Medical Informatics. The Yearbook of Medical Informatics being the “Milestone” or state-of-the-art journal and Methods of Information in Medicine being the “Science and Research” journal of IMIA, ACI intends to be the “Practical” journal of IMIA.