开发和认知的手术特定的目标在手术前设置的护理讨论:一个学习试点
Allison S Letica-Kriegel1, Roni Rosen1, Nita McNeil1
1Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA.
Journal of surgical oncology
|March 29, 2024
概括
在妇科瘤手术中实施一个新的电子模板来讨论护理目标 (GOC),改善了患者价值 (PV) 和预先护理规划 (ACP) 的文档. 为了更好的临床整合,需要进一步的修订.
科学领域:
- 在瘤学瘤学.
- 手术瘤学手术瘤学
- 以患者为中心的护理
背景情况:
- 在手术前,护理目标 (GOC) 讨论的记录不足.
- 当前的文档往往未能捕捉到基本的患者价值 (PV),阻碍了以人为中心的护理.
研究的目的:
- 评估新型电子模板的可行性和实用性,用于中国政府在妇科外科瘤学方面的讨论.
- 改进患者价值 (PV) 和预先护理规划 (ACP) 在术前环境中的记录.
主要方法:
- 一个多学科团队开发了一个电子笔记,包括讨论主题,PV和ACP.
- 该模板在妇科外科瘤诊所进行了试点测试,外科医生和高级实践提供者 (APP) 接受了关于其使用的教育.
- 通过与临床医生和患者的重点小组收集了定性数据.
主要成果:
- 在试点期间,该模板在7个外科医生/APP团队的55个笔记中使用.
- 文档包括讨论主题 (84%),PV (27%) 和ACP (7%).
- 临床医生和患者发现该倡议是有价值的,但注意到了实施方面的挑战.
结论:
- 一个特定于手术的GOC模板是可行的,以改善手术前的文档.
- 代改进是必要的,以提高模板的整合到临床工作流程,并最大限度地提高其实用性.
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