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首页> 外文期刊>Journal of the advanced practitioner in oncology >Treatment History Summary: Transplant's Solution to the Daunting Task off Medical Documentation
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Treatment History Summary: Transplant's Solution to the Daunting Task off Medical Documentation

机译：治疗历史摘要：移植到令人生畏的任务的解决方案

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Background: Our hematopoietic stem cell transplant center historically required dictated monthly interim summaries for all patients by advance practice providers (APPs). These summaries had an established detailed format that was utilized by clinical and research teams. Monthly summaries added significant work load to transplant APPs. Further evaluation of the electronic health record (EHR) has provided an alternative documentation approach to the interim summary. Our objective was to evaluate and implement a real time, efficient and concise documentation tool that would serve both clinician and research staff. Methods: A need was voiced by transplant APPs that monthly interim summary dictations and editing resulted in a significant work load burden for APPs. Monthly summaries did not consistently provide a real time outline of medical problems due to potential delay in transcription and editing. An alternative medical documentation tool that could provide real time, efficient, concise and improved access to a patient's complex medical problem list was requested. An APP documentation work group was formed and proposed different documentation structures to both transplant APPs and physicians. Specific goals for this project were: ease of data entry, no data entry limit, real time access of information, ability to access from different geographic locations via EHR, creation of data entry guidelines, and education modules for all users and auditing plan. Results: The documentation work group created a Treatment History Summary (THS) that organized transplant related specifics with past and present medical problems. The THS was presented to transplant APPs & physicians, consult services and research staff at which time feedback was incorporated into the document structure. The location of the THS in the EHR demanded that there not be any character limits to data entry, and that it be accessible to clinicians and research staff at all times. With the assistance of our IT colleagues an EHR location was identified with these characteristics. The THS structure was finalized and approved, and tutorial sessions started with transplant APPs, physicians, consult and research colleagues. The THS was piloted on a transplant team. Specific modifications were made based on the pilot findings, followed by the launch of the THS by the entire transplant service. Monthly interim summaries were discontinued. Auditing and education sessions have been ongoing with feedback and modification implementations. Conclusion: The THS provides a real time, efficient and concise method of medical documentation that serves APPs, physicians, and research staff in their care of patients. It has decreased documentation work load and allows for efficientevaluation of medically complex histories that often require care in multiple care settings (clinic, hospital, ICU) without the delay of transcription and editing. Implications: The THS provides an innovative approach to the sometimes-daunting task of medical documentation by transplant APPs. It has succeeded in providing a concise reference document that can enhance real time care of often complex transplant patients. The innovation of this document by transplant APPs has led the development of an immunotherapy THS due to launch in August 2019.
机译：背景：我们的造血干细胞移植中心历史要求通过前进实践提供者（应用）所有患者的所有患者所要求的月度临时摘要。这些摘要具有既定的详细格式，由临床和研究团队使用。每月摘要为移植应用添加了显着的工作负载。对电子健康记录（EHR）的进一步评估为中期摘要提供了另一种文件方法。我们的目标是评估和实施实时，高效，简洁的文档工具，这些工具将提供临床医生和研究人员。方法：通过移植应用表达需求，即每月临时摘要考试和编辑导致应用程序的重大工作负荷负担。由于转录和编辑的潜在延迟，每月摘要并未一致提供了医学问题的实时概述。请求替代医疗文档工具，可以提供实时，高效，简洁和改进对患者复杂的医疗问题列表的访问。形成了一个应用程序文档工作组，并提出了移植应用程序和医生的不同文档结构。该项目的具体目标是：易于数据输入，无数据输入限制，信息的实时访问，通过EHR从不同地理位置访问，创建数据输入指南，以及所有用户的教育模块和审计计划。结果：文档工作组创建了一种处理历史摘要（THS），这些概述与过去和目前的医学问题组织了移植相关细节。该THS被提交给移植的应用和医生，咨询服务和研究人员，在此时将反馈纳入文档结构。 ehr中的THS的位置要求数据输入没有任何字符限制，并且临床医生和研究人员可以随时访问。在我们的IT协助下，同事们用这些特征确定了EHR位置。 THS结构已完成并批准，并始于移植应用程序，医生，咨询和研究同事的教程。 THS被驾驶在移植团队。基于试验调查结果进行了具体修改，然后通过整个移植服务发射TH。停止每月临时摘要。反馈和修改实施，审计和教育会议一直在进行。结论：该THS提供了实时，高效，简洁的医疗文件方法，用于在他们的照顾中提供应用程序，医师和研究人员。它有减少的文档工作负载，并且允许有效地评估医学上复杂的历史，这些历史通常需要在没有延迟转录和编辑的情况下在没有延迟的多个护理环境（诊所，医院，ICU）中。含义：通过移植应用程序提供了一种创新的医疗文档任务的创新方法。它成功提供了一种简明的参考文献，可以增强经常复杂的移植患者的实时护理。通过移植应用创新本文件的创新导致了由于2019年8月推出的免疫疗法发展。

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