Applied Clinical Informatics, Inhaltsverzeichnis Appl Clin Inform 2010; 01(03): 304-317DOI: 10.4338/ACI-2010-04-RA-0023 Research Article Schattauer GmbH Evaluation of Computerized Free Text Sign-Out Notes Baseline Understanding and Recommendations T.R. Campion Jr. 1 Vanderbilt University School of Medicine, Department of Biomedical Informatics , S.T. Weinberg 1 Vanderbilt University School of Medicine, Department of Biomedical Informatics , N.M. Lorenzi 1 Vanderbilt University School of Medicine, Department of Biomedical Informatics , L.R. Waitman 2 University of Kansas Medical Center, Department of Biostatistics › Institutsangaben Artikel empfehlen Abstract Volltext als PDF herunterladen Keywords KeywordsEvaluation - continuity of patient care - hospital information systems - patient care team - qualitative research Referenzen References 1 Arora V. et al. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care 2005; 14 (06) 401-407. 2 Solet DJ. et al. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med 2005; 80 (012) 1094-1099. 3 Gandhi TK. Fumbled handoffs: one dropped ball after another. Ann Intern Med 2005; 142 (05) 352-358. 4 Philibert I, Friedmann P, Williams WT. New requirements for resident duty hours. JAMA 2002; 288 (09) 1112-1114. 5 Arora V, Johnson J. A model for building a standardized hand-off protocol. Jt Comm J Qual Patient Saf 2006; 32 (011) 646-655. 6 Vidyarthi AR. et al. Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out. J Hosp Med 2006; 1 (04) 257-266. 7 Horwitz LI. et al. Transfers of patient care between house staff on internal medicine wards: a national survey. Arch Intern Med 2006; 166 (011) 1173-1177. 8 The Joint Commission.. 2010 comprehensive accreditation manual for hospitals: the official handbook. Oakbrook Terrace IL: Joint Commission Resources; 2009 9 Patterson ES, Wears RL. Patient handoffs: standardized and reliable measurement tools remain elusive. Jt Comm J Qual Patient Saf 2010; 36 (02) 52-61. 10 Van Eaton E. Handoff improvement: we need to understand what we are trying to fix. Jt Comm J Qual Patient Saf 2010; 36 (02) 51. 11 Petersen LA. et al. Using a computerized sign-out program to improve continuity of inpatient care and prevent adverse events. Jt Comm J Qual Improv 1998; 24 (02) 77-87. 12 Van Eaton EG. et al. A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours. J Am Coll Surg 2005; 200 (04) 538-545. 13 Anderson J. et al. The Veterans Affairs shift change physician-to-physician handoff project. Jt Comm J Qual Patient Saf 2010; 36 (02) 62-71. 14 Bernstein JA. et al. Improved physician work flow after integrating sign-out notes into the electronic medical record. Jt Comm J Qual Patient Saf 2010; 36 (02) 72-78. 15 Frank G, Lawless ST, Steinberg TH. Improving physician communication through an automated, integrated sign-out system. J Healthc Inf Manag 2005; 19 (04) 68-74. 16 Kushniruk A. et al. From prototype to production system: lessons learned from the evolution of the SignOut System at Mount Sinai Medical Center. AMIA Annu Symp Proc 2003: 381-385. 17 Quan S. Signing on to sign-out: creation of a web-based patient sign-out application. Healthc Q 2005; 8 (04) 100-102. 18 Van Eaton EG. et al. Organizing the transfer of patient care information: the development of a computerized resident sign-out system. Surgery 2004; 136 (01) 5-13. 19 Cheah LP. et al. Electronic medical handover: towards safer medical care. Med J Aust 2005; 183 (07) 369-372. 20 Sarkar U. et al. SynopSIS: integrating physician sign-out with the electronic medical record. J Hosp Med 2007; 2 (05) 336-342. 21 Campion Jr. TR. et al. Analysis of a computerized sign-out tool: identification of unanticipated uses and contradictory content. AMIA Annu Symp Proc 2007: 99-104. 22 Rosenbloom ST. et al. Experience in implementing inpatient clinical note capture via a provider order entry system. J Am Med Inform Assoc 2004; 11 (04) 310-315. 23 Schnipper JL. et al. “Smart Forms” in an Electronic Medical Record: documentation-based clinical decision support to improve disease management. J Am Med Inform Assoc 2008; 15 (04) 513-523. 24 Stein DM, Wrenn JO, Stetson PD. S B. What “to do” with physician task lists: clinical task model development and electronic health record design implications. AMIA Annu Symp Proc 2009: 624-628. 25 Flanagan ME. et al. Evaluation of a physician informatics tool to improve patient handoffs. J Am Med Inform Assoc 2009; 16 (04) 509-515. 26 Stetson PD. et al. The sublanguage of cross-coverage. Proc AMIA Symp 2002: 742-746. 27 Corbin JS A. Basics of qualitative research: techniques and procedures for developing grounded theory. 3rd ed. Los Angeles: Sage; 2008 28 Friedman CP, Wyatt JC. Evaluation methods in biomedical informatics. New York: Springer-Verlag; 2005 29 Kaplan B, Shaw NT. Future directions in evaluation research: people, organizational, and social issues. Methods Inf Med 2004; 43 (03) 215-231. 30 Jelley MJ. Tools of continuity: the content of inpatient check-out lists. J Gen Intern Med 1994; 9 (Suppl. 02) 77. 31 Lee LH, Levine JA, Schultz HJ. Utility of a standardized sign-out card for new medical interns. J Gen Intern Med 1996; 11 (012) 753-755. 32 Stein DM. et al. Signout: a collaborative document with implications for the future of clinical information systems. AMIA Annu Symp Proc 2007: 696-700. 33 Erlandson DA. Doing naturalistic inquiry: a guide to methods. Newbury Park, Calif.: Sage; 1993 34 Barrows Jr RC, Busuioc M, Friedman C. Limited parsing of notational text visit notes: ad-hoc vs. NLP approaches. Proc AMIA Symp 2000: 51-55. 35 Crumlish C. The information architecture of social experience design: Five principles, five anti-patterns and 96 patterns (in three buckets). Bulletin of the American Society for Information Science and Technology 2009; 35 (06) 9-12. 36 Sidlow R, Katz-Sidlow RJ. Using a computerized sign-out system to improve physician-nurse communication. Jt Comm J Qual Patient Saf 2006; 32 (01) 32-36. 37 Kannry J, Moore C. MediSign: using a web-based SignOut System to improve provider identification. Proc AMIA Symp 1999: 550-554. 38 Kannry J, Moore C, Karson T. Discharge communique: use of a workflow byproduct to generate an interim discharge summary. AMIA Annu Symp Proc 2003: 341-345. 39 France DJ. et al. Emergency physicians’ behaviors and workload in the presence of an electronic whiteboard. Int J Med Inform 2005; 74 (010) 827-837. 40 Wong HJ. et al. Electronic inpatient whiteboards: improving multidisciplinary communication and coordination of care. Int J Med Inform 2009; 78 (04) 239-247. 41 Patterson ES, Cook RI, Render ML. Improving patient safety by identifying side effects from introducing bar coding in medication administration. J Am Med Inform Assoc 2002; 9 (05) 540-553. 42 Unertl KM, Weinger MB, Johnson KB. Applying direct observation to model workflow and assess adoption. AMIA Annu Symp Proc 2006: 794-798. 43 Unertl KM. et al. Describing and modeling workflow and information flow in chronic disease care. J Am Med Inform Assoc 2009; 16 (06) 826-836.
