トークからテキストへ:医師と患者のコミュニケーション研究の弧をリアルタイム訪問文書化に拡張する
1Medicine and Geriatrics, Regenstrief Institute, Indiana University School of Medicine, United States.
Patient education and counseling
|February 13, 2026
まとめ
電子医療記録 (EHR) の普及は,医師と患者のコミュニケーションに課題をもたらしています. ドキュメンテーション・ウィズ・ドクターリング (DWD) は,患者のケアに悪影響を及ぼし,さらなる調査を必要とします.
科学分野:
- 医療コミュニケーション 医療コミュニケーション
- 健康情報科学とは
- クリニカル・プラクティスの実践
背景:
- 医師と患者のコミュニケーションの研究は,90年近く前に始まった以来,著しく進化してきました.
- オーディオとビデオの録音は,臨床相互作用の微妙な微妙さを分析する上で重要な役割を果たしてきました.
- 電子医療記録 (EHR) の臨床実務への統合は,ほぼ普遍的になっており,2023年までに米国の医師の診療所の90%がそれらを利用しています.
研究 の 目的:
- 直接的な観察に基づいた医師と患者のコミュニケーションに関する研究の歴史的概要を提供する.
- "非常に効果的な臨床医の4つの習慣"の枠組みの発展を記述する.
- 医療を同時に提供しながら電子医療記録 (EHR) に記録する (Documenting While Doctoring - DWD) のコミュニケーションと成果への影響を検証する.
主な方法:
- 医師と患者のコミュニケーションに関する観察研究の歴史的レビュー.
- "非常に効果的な臨床医の4つの習慣"の枠組みの説明.
- 患者との接触中にEHRの使用をガイドするために,POISEDメモニックの導入.
主要な成果:
- 試験室へのEHRの移行は,効率化と請求の圧力により増加しています.
- DWDが医師と患者のコミュニケーションとケア成果に及ぼす影響に関して,重要な研究ギャップが存在しています.
- 新興の証拠は,DWDは,臨床医の注意をそらすこと,不正確なデータ記録,そして潜在的に貧しい患者のアウトカムにつながる可能性があることを示しています.
結論:
- さらなる大規模な研究が,さまざまな医療専門分野と患者集団にわたって必要とされています.
- コミュニケーション,ドキュメント,技術の相互作用を理解することは,医師と患者の関係を最適化するために不可欠です.
- DWDのコストとメリットは,ベストプラクティスを伝えるための包括的な調査を必要とします.
関連する概念動画
Role of Communication in the Nursing Process III: Evaluation and Documentation
2.1K
A successful patient outcome depends mainly on the evaluation stage of the nursing process. Evaluation determines effectiveness by reviewing what was done previously after the completion of nursing interventions. Every time a healthcare professional steps in or administers treatment, they must reassess or evaluate the action to ensure the intended result. During the evaluation phase, there are three probable patient outcomes:
2.1K
Communication
8.8K
Communication between two animals occurs when one animal transmits an information signal that causes a change in the animal that receives the information. Organisms communicate with one another in a host of different ways. Signals can be auditory, chemical, visual, tactile, or a combination of these. Communication is a critical behavioral adaptation that promotes survival, growth, and reproduction.
8.8K
Communication
11.8K
Sharing information, concepts, and emotions to foster mutual understanding is communication. The sender, recipient, and transaction must be considered in this manner. The sender is the person who shares the message, the recipient is the person who receives and understands the message, and the transaction is the method used to deliver the message and the variables that affect the communication's context and surroundings. The nurse-client connection is built on therapeutic communication.
11.8K
Arc Length Function
63
The arc length function represents the total distance traveled along a smooth curve measured from a fixed starting point to a variable endpoint. For curves that are continuous and differentiable, arc length provides a precise way to quantify distance when straight-line approximations are insufficient.To derive arc length, the curve is divided into many small segments. Each segment is approximated by a straight line whose length depends on the horizontal and vertical changes over that interval.
63
Sleepwalking and Sleep Talking
1.1K
Somnambulism, commonly known as sleepwalking, involves individuals engaging in activities ranging from simple walking to more complex behaviors such as driving. Sleepwalking typically occurs during the slow-wave sleep stages 3 and 4 early in the night when the person is not dreaming, contradicting the myth that sleepwalkers are acting out their dreams.
Factors that increase the likelihood of sleepwalking include sleep deprivation and alcohol consumption. Contrary to common beliefs, it is safe...
Factors that increase the likelihood of sleepwalking include sleep deprivation and alcohol consumption. Contrary to common beliefs, it is safe...
1.1K
Real Time RT-PCR
65.5K
Real-time reverse transcription-polymerase chain reaction, or Real-time RT-PCR, is an analytical tool used to determine the expression level of target genes. The method involves converting mRNA to complementary DNA with the help of an enzyme known as reverse transcriptase, followed by the PCR amplification of the cDNA. These two processes can be performed simultaneously in a single tube or separately as a two-step reaction.
The real-time quantification of the number of amplified products is...
The real-time quantification of the number of amplified products is...
65.5K


