背景:研究表明,临床医生经历的文档负担可能会导致不太直接的患者护理,错误增加,对工作的不满。在医疗保健系统中实施有效的策略以减轻文档负担,可以提高临床医生的满意度并增加与患者在一起的时间。然而,关于减少文献负担的循证干预措施的文献存在空白.
目的:本综述的目的是确定和全面总结与文献减负工作相关的科学状况。
方法:遵循JoannaBriggsInstitute《证据综合手册》和系统评价和Meta分析扩展范围评价(PRISMA-ScR)指南,我们对多个数据库进行了全面搜索,包括PubMed,Medline,Embase,CINAHL完成,Scopus,和WebofScience。此外,我们搜索了灰色文献,并使用谷歌学者来确保全面审查。两名审稿人独立筛选标题和摘要,其次是全文回顾,由第三位审稿人解决任何差异。进行数据提取并创建证据表。
结果:共纳入34篇文献,2016年至2022年出版,其中大部分集中在美国。所描述的努力可以分为医学抄写员,工作流改进,教育干预,用户驱动的方法,基于技术的解决方案,组合方法,和其他策略。这些努力的结果往往导致文档时间的改进,工作流效率,供应商满意度,和病人互动。
结论:本范围审查提供了卫生系统文件减负工作的全面总结。文献中报告的积极成果强调了这些努力的潜在有效性。然而,需要更多的研究来确定普遍适用的最佳实践,应考虑医疗团队成员之间的负担转移,教育质量,临床医生参与,和评价方法。
BACKGROUND: Studies have shown that documentation burden experienced by clinicians may lead to less direct patient care, increased errors, and job dissatisfaction. Implementing effective strategies within health care systems to mitigate documentation burden can result in improved clinician satisfaction and more time spent with patients. However, there is a gap in the literature regarding evidence-based interventions to reduce documentation burden.
OBJECTIVE: The objective of this
review was to identify and comprehensively summarize the state of the science related to
documentation burden reduction efforts.
METHODS: Following Joanna Briggs Institute Manual for Evidence Synthesis and Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines, we conducted a comprehensive search of multiple databases, including PubMed, Medline, Embase, CINAHL Complete, Scopus, and Web of Science. Additionally, we searched gray literature and used Google Scholar to ensure a thorough
review. Two reviewers independently screened titles and abstracts, followed by full-text
review, with a third reviewer resolving any discrepancies. Data extraction was performed and a table of evidence was created.
RESULTS: A total of 34 articles were included in the review, published between 2016 and 2022, with a majority focusing on the United States. The efforts described can be categorized into medical scribes, workflow improvements, educational interventions, user-driven approaches, technology-based solutions, combination approaches, and other strategies. The outcomes of these efforts often resulted in improvements in documentation time, workflow efficiency, provider satisfaction, and patient interactions.
CONCLUSIONS: This scoping
review provides a comprehensive summary of health system
documentation burden reduction efforts. The positive outcomes reported in the literature emphasize the potential effectiveness of these efforts. However, more research is needed to identify universally applicable best practices, and considerations should be given to the transfer of burden among members of the health care team, quality of education, clinician involvement, and evaluation methods.