在护理目标注释中,描述时间限制试验的文档
Gina M Piscitello1, Robert M Arnold2, Jane O Schell1
1Division of General Internal Medicine (G.P., J.S.), Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Palliative Research Center (G.P., J.S.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
Journal of pain and symptom management
|April 19, 2025
概括
时间有限的试验 (TLT) 很少被记录在重病患者的护理目标说明中. 需要进一步的研究来理解和改进这些重要的护理计划的文档.
科学领域:
- 医学伦理 医学伦理
- 抚慰性护理是一种缓解性护理.
- 医疗信息学 医疗信息学
背景情况:
- 时间有限试验 (TLT) 是维持生命治疗的合作计划,指导恢复和舒适护理之间的决策.
- 有效的TLT需要在护理目标 (GOC) 讨论中提供明确的文件.
研究的目的:
- 为了确定TLT文档的频率,在标准化的中国政府笔记中.
- 确定与已记录的TLTs相关的患者和临床医师因素.
- 分析中国政府文件中TLT的描述方式.
主要方法:
- 来自21家医院的5475个标准化中国政府模板笔记 (2021-2023) 的回顾性横截面研究.
- 利用描述性统计和有针对性的内容分析来评估文档实践.
主要成果:
- 只有1%的中国政府纸币引用了TLT.
- 具有TLT文件的患者年轻,更有可能没有保险,并且在医院死亡率或出院到长期急性护理的比例更高.
- TLT注意到更频繁地记录了预后,但更少地记录了代码状态的变化.
结论:
- 在中国政府为重症患者的标准化说明中,TLT很少被记录在案.
- 低的文档化率凸显了护理规划和沟通方面的差距.
- 需要进一步调查,以解决电子健康记录中TLT文档的障碍.
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