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Medical Records Reviews (MRR) are commonly used in research and quality activities in health care, however, there is a paucity of literature offering a step by step guide to devising a reliable, user-friendly tool.This instructional paper focuses on the stages used to design and implement successful MRR using examples from two reviews in Australian rural hospitals investigating the responses of Registered Nurses to patient deterioration, and guided by time series principals.The MRR were conducted in two rural hospitals in conjunction with a simulation learning intervention where nurses rehearsed clinical management of a deteriorating patient. A six-step template is presented to guide practitioners on how to design and use a MRR tool.When well-planned and appropriately used, MRR provides an excellent means for examining patient outcomes in addition to safety and quality of care.

作者:Tracy, McConnell-Henry;Simon, Cooper;Ruth, Endacott;Joanne, Porter;Karen, Missen;Louise, Sparks

来源:Contemporary nurse 2015 年 50卷 1期

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作者:
Tracy, McConnell-Henry;Simon, Cooper;Ruth, Endacott;Joanne, Porter;Karen, Missen;Louise, Sparks
来源:
Contemporary nurse 2015 年 50卷 1期
标签:
chart audit content validity emergency medical records review relevance simulation
Medical Records Reviews (MRR) are commonly used in research and quality activities in health care, however, there is a paucity of literature offering a step by step guide to devising a reliable, user-friendly tool.This instructional paper focuses on the stages used to design and implement successful MRR using examples from two reviews in Australian rural hospitals investigating the responses of Registered Nurses to patient deterioration, and guided by time series principals.The MRR were conducted in two rural hospitals in conjunction with a simulation learning intervention where nurses rehearsed clinical management of a deteriorating patient. A six-step template is presented to guide practitioners on how to design and use a MRR tool.When well-planned and appropriately used, MRR provides an excellent means for examining patient outcomes in addition to safety and quality of care.