在开放注释时代,以患者为中心的文档指导方针:定性研究
Anita Vanka1,2, Katherine T Johnston2,3, Tom Delbanco1,2
1Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States.
JMIR medical education
|January 20, 2025
概括
临床医生应该使用以患者为中心的文档来赋予患者权力,并尽量减少伤害,特别是在新的开放笔记访问时. 这项研究为敏感的医疗记录语言制定了10条指导方针.
科学领域:
- 医疗信息学 医疗信息学
- 患者沟通 患者沟通
- 健康文档 卫生文档
背景情况:
- 美国患者现在有联邦授权的电子访问临床医生笔记 (开放笔记).
- 虽然有好处,但一些患者报告说,由于记录内容,他们感到被评判或污名化.
- 以患者为中心的文档对于减轻潜在危害和赋予患者权力至关重要.
研究的目的:
- 为医疗记录文件制定明智的指南.
- 支持医疗保健机构的开放和透明沟通.
主要方法:
- 焦点小组由27名参与者组成,包括医生,患者和教育工作者.
- 一个结构化的决策指南促进了小组会议.
- 一个代编码过程被用来从定性数据中识别主题.
主要成果:
- 作为初步框架,确定了十个重要的文件准则.
- 主题是通过将一级代码分组成二级主题来生成的.
结论:
- 该研究确定了以患者为中心的文档的10个离散主题.
- 这些主题可以指导临床医生使用和传播敏感文档实践.
相关概念视频
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