探讨心脏手术后患者 Delirium 的文档:一个回顾性患者记录研究
Satu Poikajärvi1, Laura-Maria Peltonen, Eriikka Siirala
1Author Affiliations: Faculty of Medicine, Department of Nursing Science, University of Turku (Prof Poikajärvi, Dr Peltonen, Prof Salanterä, and Dr Junttila); Department of Perioperative and Intensive Care, University of Helsinki and Helsinki University Hospital (Prof Poikajärvi); Research Services, Turku University Hospital (Dr Siirala); Faculty of Technology, Department of Computing, University of Turku (Dr Heimonen); Department of Computer Science, School of Science, Aalto University (Dr Moen); Turku University Hospital (Prof Salanterä); Nursing Research Center, Helsinki University Hospital and University of Helsinki (Dr Junttila), Finland.
心脏外科手术患者痴呆症症状的记录有所改善,但关键指标,如注意力不集中,往往被忽视. 改进的EHR分析可以帮助早期发现心脏外科手术后心脏错觉的治疗和护理计划.
科学领域:
- 医疗信息学 医疗信息学
- 关键护理医学 关键护理医学
- 老年精神病学是一门精神病学专业.
背景情况:
- 痴呆症是心脏手术后的常见并发症,影响患者的结果.
- 电子健康记录 (EHR) 为研究妄想表现和管理提供了宝贵的资源.
- 了解文档模式对于改善患者护理和信息传输至关重要.
研究的目的:
- 描述心脏外科手术患者的EDS中 Delirium 症状的记录.
- 分析两个不同的时间段 (2005-2009年和2015-2020年) 之间 Delirium 文献的演变.
- 识别妄症护理系统性记录和信息传输方面的差距.
主要方法:
- 患者记录的回顾性,比较性和描述性研究.
- 随机选择的护理情节,用模板注释,包括妄想症状,治疗和不良事件.
- 用于定量和描述性分析,手动将患者分为非妄想型 (n=257) 和可能妄想型 (n=172) 组.
主要成果:
- 随着时间的推移,记录失方向,记忆问题和混乱思维等症状的情况有了显著的改善.
- 错觉的主要指标,特别是注意力不集中和意识变化,很少被记录下来.
- 缺乏对妄的可能性及其护理的系统性记录,特别是在出院摘要和护理笔记中.
结论:
- 虽然一些 Delirium 症状记录有所改善,但关键元素在 EHR 中仍未得到充分记录.
- 当前的文档化做法阻碍了对患者妄想状态和护理的全面了解.
- 在EHR中先进的机器学习可以增强心脏手术后心脏病的早期检测,护理规划和护理连续性.
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