在患者住院期间护理文档模式的变化
Rachel Y Lee1, Christopher Knaplund1, Jennifer Withall2
1Columbia University, Department of Biomedical Informatics, New York, NY.
在急症和重症监护机构中,护理文档存在很大差异. 护士根据患者的需要调整他们的实践,表明需要个性化护理和文档策略.
科学领域:
- 护理信息学 护理信息学
- 临床文档 临床文档
- 改善医疗保健质量 改善医疗保健质量
背景情况:
- 护理文档对于患者护理的持续性和质量评估至关重要.
- 文档的变化可能会影响临床决策和资源分配.
- 了解文档模式对于优化电子健康记录 (EHR) 系统至关重要.
研究的目的:
- 为了调查生命体征和笔记的护理文档的变化.
- 检查记录模式在住院期间,记录类型和患者的并发症之间有何差异.
- 探索护理文档的适应性,以应对患者的病情.
主要方法:
- 从急性护理和ICU设置中对护理文档数据的回顾性分析.
- 统计检查与住院时间,文档类型和患者并发性疾病相关的文档模式.
- 对不同护理环境之间的记录实践进行比较分析.
主要成果:
- 在医院住院期间的护理文档模式中观察到显著的变化.
- 根据文档类型 (例如,生命体征与进度笔记),文档模式有很大差异.
- 患者的并发症与明显的护理文档变化有关.
结论:
- 护士根据患者不断变化的需求和临床状况动态调整文档.
- 研究结果支持制定个性化护理计划和量身定制的文档方法.
- 对护理工作量管理,临床决策支持和EHR优化的影响是显著的.
更多相关视频
10:38Observational Study Protocol for Repeated Clinical Examination and Critical Care Ultrasonography Within the Simple Intensive Care Studies
Published on: January 16, 2019
11:21Methodology for Establishing a Community-Wide Life Laboratory for Capturing Unobtrusive and Continuous Remote Activity and Health Data
Published on: July 27, 2018
相关概念视频
Guidelines for Nursing Documentation I
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
Guidelines for Nursing Documentation II
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.
Formats for Nursing Documentation
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history,...
Documentation in Long-Term and Home Healthcare Setting
Long-Term Care Facilities
Legal Guidelines for Documentation
Role of Communication in the Nursing Process III: Evaluation and Documentation
