导航复杂的护理文档,当患者可以访问内容:一个定性研究
Birgitte Lerbæk1,2, Kathrine Hoffmann Kusk3, Lone Jørgensen3,4
1Unit for Psychiatric Research, Psychiatry-Aalborg University Hospital, Aalborg, Denmark.
Journal of advanced nursing
|October 1, 2024
概括
注册护士 (RN) 发现记录患者护理复杂,当电子健康记录是患者可访问的. 这影响了护士与病人之间的关系和知识共享,需要仔细考虑记录实践.
科学领域:
- 护理信息学 护理信息学
- 健康信息管理 管理健康信息
- 以患者为中心的护理
背景情况:
- 电子病例记录 (EPR) 越来越容易为患者提供.
- 这种可访问性为医疗保健专业人员在记录患者护理方面提出了新的挑战.
- 了解护士的经验对于优化EPR系统至关重要.
研究的目的:
- 探索丹麦注册护士 (RN) 在患者可以访问内容时如何在EPR中记录护理护理的经验.
- 识别RN在这个不断变化的文档环境中所面临的复杂性和挑战.
主要方法:
- 使用六个重点小组进行定性研究设计.
- 参与了来自丹麦大学医院住院病房的31名RN.
- 使用定性内容分析分析的数据.
主要成果:
- 出现了三个关键主题:"权衡自己的言语"",建立信任或引发冲突"和"冒着失去知识的风险".
- 这些主题突出了RN由于患者访问文档而承担的复杂导航.
- 研究结果表明,这可能会对护士与病人关系和知识保留产生影响.
结论:
- 患者访问护理文档需要RNs管理语言,关系和知识保存.
- 虽然潜在地提高了文档的重点,但它可能会改变实践,损害EPR作为工作工具.
- 迫切需要确定敏感观察的安全共享,并优先考虑患者参与记录.
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