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Methods of Documentation VI: Case Management Model01:15

Methods of Documentation VI: Case Management Model

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The case management model is a multidisciplinary approach that involves healthcare professionals from diverse disciplines, such as physicians, nurses, therapists, social workers, and pharmacists, working collaboratively to address the various needs of patients. Each healthcare professional brings unique expertise and perspectives, contributing to a more comprehensive understanding of the patient's condition and tailoring treatment plans accordingly.
For example, a patient with a chronic...
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Nursing Clinical Information System01:27

Nursing Clinical Information System

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Nursing Clinical Information System (NCIS)
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:
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Statistical Software for Data Analysis and Clinical Trials01:12

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Statistical software is pivotal in data analysis and clinical trials by providing tools to analyze data, draw conclusions, and make predictions. These software packages range from simple data management applications to complex analytical platforms, supporting various statistical tests, models, and simulation techniques. Their significance lies in their ability to handle vast amounts of data with precision and efficiency, enabling researchers to validate hypotheses, identify trends, and make...
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Nursing diagnoses represent a problem validated by major defining characteristics. There are four categories of nursing diagnoses: problem-focused, risk, health promotion or wellness, and syndrome. The anatomy of a nursing diagnosis includes three components: problem statement or diagnostic label, defining characteristics, and related factors.
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A nursing diagnosis is written when the nurse recognizes a cluster of essential patient data indicating health problems treated with independent nursing interventions. The standardized terminologies of a nursing diagnosis help nurses identify and treat patients' problems. Every electronic health record that uses nursing diagnosis must employ standard diagnostic terminology. Developing an efficient, individualized care plan begins with accurate nursing diagnoses.
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The nurse documents nursing diagnoses and enters them into the patient record. The identified patient's nursing diagnosis is either written out with a plan of care or entered into the electronic health record.
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标准化临床病例的计算机支持协作设计:算法开发和验证.

Sergio Guinez-Molinos1, Félix Buendía-García2, José-Luis Sierra-Rodríguez3

  • 1School of Medicine, Universidad de Talca, Talca, Chile.

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这项研究开发了一个可互操作的工作流生态系统,用于创建和共享医学临床病例. 它允许协作案例设计,通过HL7 FHIR标准进行出口,并在学习管理系统 (LMS) 中部署.

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基于案例的学习.临床病例 临床病例 临床病例合作的临床病例.协作学习是一种协作式的学习.互操作性互操作性互操作性的互操作性标准 标准 标准 标准 标准

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科学领域:

  • 医疗教育 技术 技术 医学教育
  • 医疗信息学 医疗信息学
  • 协作式学习是一种协作式学习.

背景情况:

  • 计算机支持的协作临床病例创建至关重要,但缺乏互操作性.
  • 现有的平台孤立知识,阻碍案例重复使用和共享.
  • 需要一个标准化的工作流程来民主化医学教育资源.

研究的目的:

  • 展示一个可行的工作流生态系统,用于协作临床病例创建,出口和部署.
  • 能够在不同的教育平台上无共享临床病例.
  • 克服孤立,专有教育系统的局限性.

主要方法:

  • 开发了一个三平台生态系统:Mosaico用于案例设计,Clavy用于存储库管理,Moodle作为LMS.
  • 使用健康7级 (HL7) 快速医疗互操作性资源 (FHIR) 用于病例出口.
  • 采用电子学习标准 (IMS-CP,SCORM) 在学习管理系统 (LMS) 中部署.

主要成果:

  • 成功实施了一个可互操作的生态系统,自动化案例创建,HL7 FHIR出口和LMS部署.
  • 生成的指令管理系统内容包装 (IMS-CP) 兼容标准LMSs.
  • 以标准,可互操作的格式展示了临床病例的民主化和共享.

结论:

  • 为跨平台临床病例管理提出,实施和验证了基于标准的工作流.
  • 生态系统有效地转换了在LMS中基于Web部署的协作创建的案例.
  • 实现异质技术之间的互操作性,以加强医学教育资源共享.