在初级保健访问期间缺少临床信息
Peter C Smith1, Rodrigo Araya-Guerra, Caroline Bublitz
1Department of Family Medicine, University of Colorado Health Sciences Center, Denver, USA. peter.smith@uchsc.edu
主要护理临床医生经常遇到缺少的临床信息,影响患者的护理,导致延误. 这项研究强调了需要更好的信息系统,以改善患者安全和护理协调.
科学领域:
- 医疗保健服务研究 医疗服务研究
- 临床信息学 临床信息学
- 患者安全 患者安全
背景情况:
- 初级保健协调在很大程度上依赖于全面的临床信息.
- 缺乏临床信息是已知的障碍,但在初级保健机构中尚未得到广泛研究.
研究的目的:
- 调查和描述初级保健临床医生在患者访问期间缺乏临床信息的经验和看法.
主要方法:
- 在32个初级保健诊所的253名临床医生进行了横截面调查.
- 收集了1614名患者访问的数据,记录了缺乏临床信息的频率,类型和感知影响.
主要成果:
- 临床医生报告说,13.6%的访问中缺少信息,包括实验室结果,信件和药物详细信息.
- 缺少的信息往往是临床系统之外的,44%被认为可能导致不良影响,59.5%导致延误或额外的服务.
- 时间花在寻找缺失的数据上,新患者,多种医疗问题和缺乏完整的电子记录等因素与更高的报告率有关.
结论:
- 缺少临床信息是初级保健中普遍存在的问题,消耗资源并可能伤害患者.
- 建议进行进一步的研究,以验证这些发现,并通过前性研究探索缺少信息的原因和后果.
更多相关视频
07:50A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts
Published on: September 20, 2018
06:28E-Patient Counseling Trial (E-PACO): Computer Based Education versus Nurse Counseling for Patients to Prepare for Colonoscopy
Published on: August 1, 2019
相关概念视频
Healthcare Associated Infections II: Preventive Measures
The best practices for preventing healthcare-associated infections include hand hygiene, patient risk...
Nursing Assessment
The nurse collects all aspects of the patient's health in the initial assessment, establishing priorities for ongoing focused assessments and...
Data Collection I
Data Collection III
The principles to begin the physical assessment include conducting a comprehensive or problem-related history in a quiet, well-lit room, emphasizing privacy and comfort for the patient.
Nursing Clinical Information System
A Nursing Clinical Information System (NCIS) is a specialized type of healthcare information system tailored to meet the unique needs of nursing practice. It incorporates the principles of nursing informatics to streamline information management and improve the quality of care delivery.
Critical attributes of NCIS include:
Assessment of the Cardiovascular System I: Subjective Data
Initial Enquiry
Ask the patient about their primary concern and thoroughly explore all reported symptoms.
Medical History
Investigate past illnesses affecting the cardiovascular system, such as angina, anemia, rheumatic fever, congenital heart disease, stroke, thrombophlebitis, dysrhythmias, varicosities
Inquire about symptoms...
