患者撰写的医疗记录II:对精神病护理的无知方法
Chizuru Tsubonouchi1, Midori Asano2, Naoki Nomura3
1Department of Integrated Health Sciences, Nagoya University Graduate School of Medicine, Nagoya City, Japan; Nihon Fukushi University, Department of Nursing, Tokai City, Aichi, Japan.
Archives of psychiatric nursing
|July 21, 2024
概括
为精神病护理开发的患者授权医疗记录 (PAMR) 赋予患者表达疾病改善策略的权力. 这种叙事工具,通过护士的合作和对话来加强,促进治疗进步和团队协同作用.
科学领域:
- 精神病学护理 精神病学护理
- 心理健康 治疗方法 治疗方法
- 以患者为中心的护理
背景情况:
- 患者撰写的医疗记录 (PAMR) 是精神病患者在护理支持下创建的叙事处方.
- 以前的研究表明PAMR的治疗效果和患者对疾病管理的准确自我评估.
研究的目的:
- 综合检查使用PAMR的过程,包括创建记录和后续对话.
- 通过基于对话的记录解释来证明患者的潜力是如何增强的.
- 重申PAMR在精神病治疗中的有效性和治疗价值.
主要方法:
- 使用患者撰写的医疗记录 (PAMR) 作为叙事工具.
- 包含对文本解释的后续对话会议.
- 在对话中采用对话式的"不知道"方法来探索患者的观点.
- 通过后续会议促进治疗过程和合作.
主要成果:
- 该研究详细介绍了PAMR实施和后续行动的完整过程.
- 基于对话的解释有效地利用和扩大患者的潜力.
- 后续会议可以提高治疗成果和跨学科合作.
结论:
- 患者授权的医疗记录 (PAMR) 是精神病护理中的合法和有效工具.
- 该过程将叙事记录与指导对话相结合,支持患者的自我理解和治疗进步.
- PAMR促进了患者,医疗保健提供者和家庭之间的合作,改善了整体护理.
相关概念视频
01:26Methods of Documentation II: POMR
932
The Problem-Oriented Medical Record (POMR) revolutionized medical record-keeping by introducing a systematic approach focusing on the patient's problems rather than merely listing symptoms. Dr. Lawrence Weed's introduction of this method in the 1960s marked a significant advancement in medical documentation. The POMR framework consists of four key components: the database, problem list, plan of care, and progress notes.
932
01:10Documentation of Nursing Diagnosis
1.2K
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.
In some settings, data-driven computerized decision support systems are in place, allowing for more accurate nursing diagnoses. The database within one of these systems includes diagnostic labels defining characteristics, activities, and indicators for nursing. A nurse enters...
In some settings, data-driven computerized decision support systems are in place, allowing for more accurate nursing diagnoses. The database within one of these systems includes diagnostic labels defining characteristics, activities, and indicators for nursing. A nurse enters...
1.2K
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
01:23Ethical Standards II
660
Ethical standards are the backbone of nursing practice, guiding nurses as they interact with patients, families, and colleagues. These standards are crucial for providing safe, empathetic care centered on the patient's needs.
Nurses are entrusted with upholding various ethical principles and standards. Nurses forge solid therapeutic relationships using trust, empathy, autonomy, confidentiality, and professional competence.
Confidentiality is crucial, embodying respect for individual privacy...
Nurses are entrusted with upholding various ethical principles and standards. Nurses forge solid therapeutic relationships using trust, empathy, autonomy, confidentiality, and professional competence.
Confidentiality is crucial, embodying respect for individual privacy...
660
01:27Types of Records I: Unit and Nurses Records
1.1K
Unit records in healthcare settings document the patient's treatment history, including interventions, medications, diagnostic and laboratory results, progress notes, personal care needs, vital signs, and other medical information. They are crucial for managing patient care, aiding healthcare professionals in providing quality treatment and informed decision-making.
Unit records can be divided into two main types: administrative records and clinical records.
Administrative records in...
Unit records can be divided into two main types: administrative records and clinical records.
Administrative records in...
1.1K
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