创伤信息护理要素的文档,用于在袭击创伤后住院的年轻人
Insia Zufer1, Rebecca L Fix2, Elizabeth Stone3
1Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University School of Medicine, Baltimore, Maryland.
The Journal of surgical research
|February 15, 2024
概括
创伤信息化护理 (TIC) 文档在儿童创伤患者中比成人创伤患者更为常见,但关键的安全评估很少被记录. 改善ICT文档可以帮助预防青少年幸存者的未来暴力和创伤后果.
科学领域:
- 创伤护理的护理人员.
- 公共卫生 公共卫生
- 医疗服务研究 医疗服务研究
背景情况:
- 暴力创伤伤害,包括枪支暴力,显著影响个人和社区的健康.
- 创伤知情护理 (TIC) 对于培养性和预防创伤幸存者的反复暴力至关重要.
- 对于在从创伤中恢复过来的患者中实施TIC存在有限的协议.
研究的目的:
- 描述电子医疗记录中的创伤信息元素的文档.
- 确定在创伤信息化护理实践中进行干预的机会.
- 在一个单一的学术四级护理中心分析TIC文档.
主要方法:
- 对因袭击创伤入院的年轻患者 (12-23岁) 的回顾性图表审查.
- 来自儿科 (n=50) 和成人创伤 (n=200) 服务的电子病历分析 (2016-2021).
- 描述性统计和千平方分析,以比较服务之间的文档化率.
主要成果:
- 在儿科 (96%) 和成人 (82.5%) 的创伤患者中,有很高的百分比记录了至少一个创伤信息元素.
- 社会工作者最常记录的创伤信息元素,疼痛评估和社会支持是常见的.
- 对自杀念头,报复性暴力和使用枪支的安全评估很少被记录,特别是在成人创伤患者中.
结论:
- 研究结果揭示了为遭受袭击创伤的年轻人开发创伤信息化的干预措施的重大机遇.
- 标准化的ICT文档可以提高暴力重伤的风险评估.
- 改进的ICT文档可能有助于减轻创伤的长期后果.
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
1.0K
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.
1.0K
01:29Documentation in Long-Term and Home Healthcare Setting
892
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
892
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
01:20Introduction 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
01:27Post-traumatic Stress Disorder
34
Post-traumatic stress disorder (PTSD) is a psychiatric condition that arises following exposure to traumatic events such as natural disasters, forced displacement, or severe accidents. It significantly impairs individuals' ability to cope with daily activities and disrupts their emotional and psychological equilibrium.
Symptoms and Behavioral Manifestations
A spectrum of distressing symptoms characterizes PTSD. Recurrent flashbacks, where individuals involuntarily relive traumatic events,...
Symptoms and Behavioral Manifestations
A spectrum of distressing symptoms characterizes PTSD. Recurrent flashbacks, where individuals involuntarily relive traumatic events,...
34