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Challenges of implementing a standardized process for discharge summaries (5 years experience)

机译:实施标准化的排放汇总程序的挑战(5年经验)

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Introduction Discharge summaries are essential documents to provide a long-lasting record of a patient's visit to a hospital. It provides an effective method of communication between various hospital services and primary care providers. We conducted a study recently in KFSH&RC recommending that every admitted patient to the Pediatric Department must have a discharge summary initiated as soon as possible within the first five days of hospitalization and to be updated periodically until its completion on the patient's discharge day. Results of this study showed that most of the patients received their discharge summaries within the time limit as recommended by the JCIA standard. Objectives The aim of this paper is to present our department's experience in regard to the difficulties, challenges, and outcomes of the adopted work flow for discharge summaries over a period of five years. Methods The residents have been instructed to initiate the discharge summaries as soon as possible within the first five days of hospitalization for every patient admitted under the Department of Pediatrics regardless of the expected discharge date. Afterward, it will be the responsibility of the attending junior and senior residents to update the summaries on regular basis as long as the patient under their care. They should transfer the updated summary to the coming resident that will take over the medical care until the discharge day when the most recent update will be forwarded to the attending consultant for final review and signature. Results Between 2011 and 2016, a significant drop in the number of delinquent records was noted. From 1131 delinquent records at the end of the fourth quarter of 2011, the number has fallen to 15 in the fourth quarter of 2016. Furthermore, compliance to JCIA documentation standards showed sustained improvement since the initiation of the project. The department used to score around 50% in the discharge documentation compliance rate which has improved to be maintained around 80%s in average. Conclusions Every new project concerning the quality of patient care provided in any institution is expected to face multiple challenges and difficulties. Proper identifications of the challenges, standardize approach for solutions, sustainability of quality monitoring for an improvement projects can maintain the success for any new project.
机译:简介出院总结是必不可少的文件,可以长期记录患者的出诊情况。它提供了各种医院服务与初级保健提供者之间进行交流的有效方法。我们最近在KFSH&RC中进行了一项研究,建议每位入院的儿科患者必须在住院的前五天内尽快启动出院总结,并定期进行更新,直到其出院当天完成。这项研究的结果表明,大多数患者在JCIA标准建议的时限内接受了出院总结。目标本文的目的是介绍我们部门在过去五年中针对所采取的工作总结所面临的困难,挑战和成果的经验。方法指示住院医师在住院的前五天内尽快对每位儿科住院的患者进行出院总结,无论预期出院日期如何。之后,只要患者在他们的照料下,参加活动的初级和中级居民都有责任定期更新摘要。他们应将更新后的摘要传送给即将接管的居民,该居民将接管医疗服务,直到出院当天,最新的更新将转发给与会的顾问进行最终审查和签名。结果从2011年到2016年,拖欠记录的数量显着下降。从2011年第四季度末的1131个拖欠记录,到2016年第四季度,这一数字已下降到15个。此外,自项目启动以来,对JCIA文档标准的遵从性显示出持续改进。该部门过去在排放文件合规率上得分大约为50%,而现在已经提高到平均80%左右。结论任何机构中有关患者护理质量的每个新项目都将面临多重挑战和困难。对挑战的正确识别,解决方案的标准化方法,改进项目的质量监控的可持续性,可以使任何新项目保持成功。

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