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首页> 外文期刊>International Journal of Pediatrics and Adolescent Medicine >Departmental collaborative approach for improving in-patient clinical documentation (five years experience)
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Departmental collaborative approach for improving in-patient clinical documentation (five years experience)

机译：部门合作方法以改善住院病人的临床记录（五年经验）

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IntroductionHealth care institutes are cooperative areas where multiple health care services come together and work closely; physician, nurses and paramedics etc,. These multidisciplinary teams usually communicate with each other by documentation. Therefore, accurate documentation in health care organization is considered one of the vital processes. To make the documentation useful, it needs to be accurate, relevant, complete and confidential.ObjectivesThe aim of this paper is to demonstrate the effect of the collaborative work in the Department of Pediatrics on improving the quality of inpatient clinical documentation over 5 years.MethodsImproving clinical documentations went through several collaborative approaches, these include: Departmental Administration involvement, establishment of quality management team, regular departmental collaborative meeting as a monitoring and motivating tool, establishment of the residents quality team, Integration of quality projects into the new residents annual orientation, considering it as a part of the trainee personal evaluation, sending reminders to the consultants and residents on the adherence for admission note initiating and 24?h's verification, utilization of standardized template of admission note and progress note and emphasizing on the adherence to the approved medical abbreviation list only for any abbreviation to be used.ResultsDuring the period between the first quarter of 2012 to the fourth quarter of 2017; a significant improvement was noticed in the overall in-patient clinical documentation compliance rate, as it was ranging from lower 50% in 2012 and 2013, and increased gradually to reach upper 80% in the last quarters of 2016 and 2017. These figures are based on an independent audit that being done by the hospital quality management department and received by the department in a quarterly basis.ConclusionDespite multiple challenges for improving the compliance for clinical documentations, major improvement can be achieved when the collaboration and efforts among all stakeholders being shared and set as a common goal.
机译：引言卫生保健机构是合作领域，多个卫生保健服务汇聚在一起并紧密合作;医生，护士和护理人员等。这些多学科团队通常通过文档相互沟通。因此，卫生保健组织中的准确文档被认为是至关重要的过程之一。为了使文档有用，它必须准确，相关，完整和保密。目的本文旨在证明儿科的合作工作在5年内对改善住院患者临床文档质量的影响。临床文档通过几种协作方式进行了研究，包括：部门管理部门的参与，质量管理团队的建立，作为监视和激励工具的定期部门协作会议，居民质量团队的建立，将质量项目整合到新居民年度定向中，将其视为受训者个人评估的一部分，向顾问和居民发送提醒，要求他们遵守入院通知书的启动和24小时的验证，使用入院通知书和进度说明的标准化模板，并强调遵守批准的医疗程序缩写结果仅在2012年第一季度至2017年第四季度之间;总体住院患者临床文件依从率得到了显着改善，从2012年和2013年的较低50％到2016年和2017年最后一个季度逐渐上升至80％的较高水平。这些数据是基于尽管医院质量管理部门每季度都要接受一次独立审核，并接受季度审核。结论尽管在提高临床文档的依从性方面遇到了许多挑战，但在所有利益相关者之间的协作和共同努力下，可以实现重大改进。设定为共同目标。

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