用药过程需要患者记录中清晰透明的文档。不完整或不正确的药物文件可能导致不适当的临床决策和不良事件。全面评估住院用药文件的质量,我们开发了回顾性图表回顾(RCR)工具.我们报告了发展过程,该仪器的可行性,并描述我们将该仪器应用于患者记录样本。
使用RCR仪器评估纸质的横断面研究,非标准化处方和药物管理图表(MediDocQ)。
两家德国大学医院。
对2015年4月至7月间收治的1361例患者的记录进行了评估。
MediDocQ开发过程包括六个连续阶段:重点文献综述,基于网络的搜索,初始病历筛查,由项目顾问委员会审查,与专业人士和试点测试的焦点小组。最终的54项RCR仪器涵盖了药物文档的三个关键组成部分:(1)文档信息的完整性(包括处方,药物管理和prorenata(PRN)药物),(2)转录质量和(3)符合图表结构,易读性,删除和图表更正的处理。描述性统计数据以平均值表示,SD,个别项目的中位数和四分位数范围。
总的来说,54个项目中有33个项目的平均值超过0.75,表明高质量的药物文件。对于口头和PRN订单(涉及比标准订单更多的步骤)以及文档未与药物管理同时完成时,文档质量尤其受到损害。
MediDocQ是一种患者安全工具,可用于评估药物文档的质量,并确定需要干预的过程的组成部分。在我们的设置中,药物文件的标准化,特别是关于药物管理和PRN药物是一个优先事项。
The medication process requires clear and transparent documentation in patient records. Incomplete or incorrect medication documentation may contribute to inappropriate clinical decision-making and adverse events. To comprehensively assess the quality of in-hospital medication documentation, we developed a retrospective chart
review (RCR) instrument. We report on the development process, the feasibility of the instrument and describe our application of the instrument to a sample of patient records.
Cross-sectional study using an RCR instrument to evaluate paper-based, non-standardised prescription and medication administration charts (MediDocQ).
Two German university hospitals.
Records from 1361 patients admitted between April and July 2015 were evaluated.
The MediDocQ development process comprised six consecutive stages: focused literature
review, web-based search, initial patient record screening,
review by project advisory board, focus groups with professionals and pilot testing. The final 54-item RCR instrument covers three key components of medication documentation: (1) completeness of documented information (including prescription, medication administration and pro re nata (PRN) medication), (2) quality of transcriptions and (3) compliance with chart structure, legibility, handling of deletions and chart corrections. Descriptive statistics are presented as mean values, SD, median and interquartile ranges for individual items.
Overall, 33 out of 54 items resulted in mean values above 0.75, indicating high-quality medication documentation. Documentation quality was particularly compromised for verbal and PRN orders (which involve more steps than standard orders) and when documentation was not completed at the same time as medication administration.
MediDocQ is a patient safety instrument that can be used to evaluate the quality of medication documentation and identify components of the process where intervention is required. In our setting, standardisation of medication documentation, particularly regarding medication administration and PRN medication is a priority.