初级护理护士对结构化文档的经验:一个定性采访研究
Anna Dalsten Hjort1, Tora Hammar2, Karin Myrberg1,3
1Centre for Research and Development, Region Gävleborg/Uppsala University, Uppsala, Sweden.
Global qualitative nursing research
|April 28, 2025
概括
初级护理护士发现电子健康记录中的结构化文档对患者安全和在治疗慢性阻塞性肺病 (COPD) 中提供公平护理有好处. 专业自主是实现这些优势的关键.
科学领域:
- 医疗信息学 医疗信息学
- 护理实践 护理实践
- 提高质量 提高质量
背景情况:
- 医疗保健系统正在向电子健康记录 (EHR) 过渡,以提供结构化文档.
- 从EHR到国家质量注册表的直接数据传输正在增加.
- 这种转变可能会影响护士的记录实践和患者护理.
研究的目的:
- 调查初级保健护士在结构化文档和直接数据传输到国家质量注册表方面的经验.
- 探索这些做法如何影响慢性阻塞性肺病 (COPD) 患者的管理.
主要方法:
- 质量研究涉及瑞典9名初级护理护士的半结构面试.
- 护士们使用了COPD患者的结构化文档模板,将数据直接传输到质量登记册.
- 采访被转录并使用定性内容分析进行分析.
主要成果:
- 护士报告说他们遇到了一些障碍,但主要观察到结构化文档的好处.
- 关键的好处包括对患者安全和COPD患者公平护理的潜在改进.
- 专业经验和自主性被认为是最大化这些好处的关键.
结论:
- 使用直接数据传输的结构化文档显示了提高COPD初级护理中的公平护理和患者安全的潜力.
- 解决障碍和支持专业自主性对于成功实施至关重要.
- 调查结果可以为护士提供改进的文档工作程序.
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