组织对运动员训练中文档化实践的期望
Jordan S Devenney1, Matthew J Drescher2,3, Matthew J Rivera2
1Center for Sports Medicine and Performance, Indiana State University, Terre Haute.
Journal of athletic training
|July 17, 2023
概括
运动训练的监督者经常缺乏正式的文件政策和问责制,尽管他们对员工充满信心. 实施明确的标准可以改善患者护理和法律合规性.
科学领域:
- 运动医学 运动医学
- 运动员训练文件 运动员训练文件
- 医疗保健管理部门的管理.
背景情况:
- 对于体育训练中的医疗文件,没有国家标准.
- 个别组织制定自己的政策,导致变化.
- 以前的研究集中在临床医生的行为上,而不是文档中的监督角色.
研究的目的:
- 调查监督者在支持,阻碍和执行医疗文档标准方面的做法.
- 了解监管人员如何创建和传达文档政策.
- 检查体育训练中医疗记录的问责机制.
主要方法:
- 混合方法研究利用在线调查和后续访谈.
- 在NCAA成员学校监督运动教练的标准抽样 (n=64调查,n=12访谈).
- 数据分析包括描述性统计和协商一致的定性研究方法.
主要成果:
- 不到一半的监管机构报告了正式的书面政策 (48%),程序 (34%) 或时间表 (29%) 文件.
- 监管人员描述了方向,沟通,问责和目的的框架.
- 限制包括时间限制,角色优先级和关于先前培训的假设.
结论:
- 在监督员的信心和员工对记录实践的不确定性之间存在差距.
- 缺乏明确的政策,程序和问责制,阻碍了文件的一致性.
- 建立组织标准和问责制对于改善患者护理,结果和法律合规至关重要.
相关概念视频
01:06Legal Guidelines for Documentation
1.3K
The legal guidelines for nursing documentation are essential for ensuring accurate, professional, and ethical recording of patient care. The guidelines are discussed here:
1.3K
01:26Guidelines for Nursing Documentation II
1.1K
Effective documentation is an integral part of nursing practice. Here are some essential guidelines to follow when documenting patient care:
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
1.1K
01:30Guidelines for Nursing Documentation I
1.1K
Quality documentation and reporting share essential characteristics that ensure they are practical and valuable resources for those who use them. These characteristics are:
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
1.1K
01:08Role of Communication in the Nursing Process III: Evaluation and Documentation
1.3K
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:
1.3K
01:29Documentation in Long-Term and Home Healthcare Setting
931
Documentation in long-term care facilities and home healthcare settings is crucial for ensuring continuous, coordinated, and comprehensive care for patients. Each setting has its specific documentation processes and tools:
Long-Term Care Facilities
Long-Term Care Facilities
931
01:20Introduction to Documentation and Reporting
2.0K
Documentation is the systematic process of formally recording, maintaining, and communicating information.
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive...
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive...
2.0K