Accuracy of nursing home medical record information about care-process delivery: Implications for staff management and improvement
Accuracy of nursing home medical record information about care-process delivery: Implications for staff management and improvement
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DOI：
10.1111/j.1532-5415.2004.52372.x
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发表时间：
2004-08-01
影响因子：
6.3
通讯作者：
Simmons, SE
中科院分区：
文献类型：
--
作者：
Schnelle, JE;Bates-Jensen, BM;Simmons, SE
有人认为，疗养院(NHS)的文化必须改变，以提高护理质量，已设计了两项举措来实现这一目标。一项举措是通过公共报告系统向NH管理层和消费者提供驻地成果信息(质量指标)。这一举措是基于这样的假设，即居民结果与NH工作人员实施的护理过程有关，NH行业将对市场力量做出反应，并且NHS内部有适当的管理系统，可以在结果不佳时改变直接护理人员的行为。另一项人员配备倡议认为，在有可用的资源来增加直接护理人员的数量和改善工作人员培训之前，保健保健不会得到改善。这一举措还假定建立了管理人员资源的系统。不幸的是，这些举措的效果可能有限，因为在NHS中无法获得对管理直接护理提供者的行为有用的信息。关于日常护理流程实施的医疗记录记录可能非常错误，即使是最好的改善住院医生接受的护理的努力也不会成功。不准确的记录文化在很大程度上是由监管指南对NHS施加的护理期望与满足这些期望的补偿不足之间的差异造成的。如果准确的文件显示没有或不能提供符合监管指南的护理，疗养院工作人员几乎没有动力实施必要的技术来审计和确保数据质量。调查过程主要侧重于图表记录以评估质量，这进一步刺激了护理过程记录，而不是护理过程交付。本文回顾了提高NH病历文件的准确性和创建对员工培训和管理有用的数据系统的方法。
Arguments have been made that the culture of nursing homes (NHs) must change to improve the quality of care, and two initiatives have been designed to accomplish this goal. One initiative is to provide resident outcome information (quality indicators) to NH management and consumers via public reporting systems. This initiative is based on the assumptions that resident outcomes are related to care processes implemented by NH staff, the NH industry will respond to market forces, and there are management systems in place within NHs to change the behavior of direct care staff if outcomes are poor. A separate staffing initiative argues that NH care will not improve until there are resources available to increase the number of direct care staff and improve staff training. This initiative also assumes that systems are in place to manage staff resources. Unfortunately, these initiatives may have limited efficacy because information useful for managing the behavior of direct care providers is unavailable within NHs. Medical record documentation about daily care-process implementation may be so erroneous that even the best-intentioned efforts to improve the care received by residents will not be successful.A culture of inaccurate documentation is largely created by a discrepancy between care expectations placed on NHs by regulatory guidelines and inadequate reimbursement to fulfill these expectations. Nursing home staff have little incentive to implement the technologies necessary to audit and assure data quality if accurate documentation reveals that care consistent with regulatory guidelines is not or cannot be provided. A survey process that largely focuses on chart documentation to assess quality provides further incentive for care-process documentation as opposed to care-process delivery. This article reviews methods to improve the accuracy of NH medical record documentation and to create data systems useful for staff training and management.