An Evidence-based Preoperative Evaluation Documentation Template Improves Perioperative Communication.
Appl Clin Inform
; 15(1): 121-128, 2024 01.
Article
em En
| MEDLINE
| ID: mdl-38354838
ABSTRACT
OBJECTIVES:
The number of surgeries performed in the United States has increased over the past two decades, with a shift to the ambulatory setting. Perioperative complications and mortality pose significant health care burdens. Inadequate preoperative assessment and documentation contribute to communication failure and poor patient outcomes. The aim of this quality improvement project was to design and implement a preoperative evaluation documentation template that not only improved communication during the perioperative pathway but also enhanced the overall user experience.METHODS:
We implemented a revamped evidence-based documentation template in the electronic medical records of a health care organization across three internal medicine clinics on the downtown campus and seven satellite family medicine clinics. A pre- and postintervention design was used to assess the template utilization rate and clinician satisfaction.RESULTS:
The preoperative template utilization rate increased from 51.2% at baseline to 66.5% after the revamped template "went live" (p < 0.001). Clinician satisfaction with the preoperative documentation template also significantly increased (30.6 vs. 80.0%, p < 0.001).CONCLUSION:
Adopting a user-friendly, evidence-based documentation template can enhance the standardization of preoperative evaluation documentation and reduce the documentation burden.
Texto completo:
1
Coleções:
01-internacional
Base de dados:
MEDLINE
Assunto principal:
Documentação
/
Registros Eletrônicos de Saúde
Limite:
Humans
Idioma:
En
Revista:
Appl Clin Inform
/
Applied clinical informatics
Ano de publicação:
2024
Tipo de documento:
Article
País de afiliação:
Estados Unidos