Does Perioperative Documentation Transfer Reliably?

作者：Ridout Jamie^*; Aucoin Julia; Browning Anne; Piedra Katerina; Weeks Sheila

来源：Computers, Informatics, Nursing, 2014, 32(1): 37-42.

DOI：10.1097/CIN.0000000000000017

• Communication
• Documentation
• Patient safety
• Perioperative

In the complex and multiphasic perioperative process, there are many opportunities to transfer information between providers and settings. Previous studies have shown that information transfer and communication are vital to minimize risks in the perioperative setting. The aim of this study was to explore the incidence of failure to communicate vital information as the patient progressed through the six phases of the perioperative process. The systematic sample included ambulatory surgery patient records from one quarter. A failure to communicate rate was calculated as 10.2% for the 5586 entries. In the absence of a comprehensive electronic health record, a consistent method for information transfer must be used to minimize risks.

• 出版日期2014-1