儿科患者护理目标文档的内容和全面性
Hannah Riedy1, Kiira Lyons2, David J Casarett2
1Duke University School of Medicine, Durham, NC.
Journal of pain and symptom management
|May 7, 2025
概括
儿科护理目标 (GOC) 文档通常包括关键讨论元素,但可能缺乏关于终身规划的细节. 需要进一步的研究,以评估这些重要的对话的质量,为不同的儿科患者群体.
科学领域:
- 儿科缓和护理 儿科缓和护理
- 临床文档 临床文档
- 改善医疗保健质量 改善医疗保健质量
背景情况:
- 医疗目标 (GOC) 对话对于将医疗治疗与患者价值观保持一致至关重要.
- 这些讨论的全面记录对于符合目标的护理至关重要.
- 有限的研究存在于中华人民共和国儿科文献的完整性.
研究的目的:
- 评估儿科护理目标文档的内容和全面性.
- 在这些注释中识别经常和不经常记录的组件.
- 为未来对中国政府儿科文档实践的改进提供信息.
主要方法:
- 从一个学术卫生系统回顾了429份中国政府的儿科笔记 (2016年8月 - 2023年9月).
- 通过电子病历文本标记识别的笔记,适用于年龄小于18岁的患者.
- 一本中国政府的儿科编码书对七个关键组成部分进行了评估;错误的注释被排除在外.
主要成果:
- 大多数笔记 (77.9%) 来自息治疗;主治医生写了77.4%.
- 通常记录的组件包括讨论参与者 (98.1%),目标/优先事项 (87.6%) 和治疗决策 (85.3%).
- 不太频繁地记录的组件是终生规划 (33.3%) 和信息偏好 (9.8%).
结论:
- 中华人民共和国儿童医疗笔记捕捉了许多重要组成部分,但可能不完全反映了讨论的深度.
- 有机会改善终身护理规划和信息偏好方面的文档.
- 未来的研究应检查中国政府在不同儿科患者群体的文档质量.
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