儿科息护理的电子护理文档:一个范围审查
Andrea Beghè1, Stefano Mancin2, Elena Cacciapaglia3
1Registered nurse, ASST Rhodense, Garbagnate Milanese, Milan, Italy.
International journal of palliative nursing
|June 19, 2025
概括
电子医疗记录 (EMR) 中的电子护理文档增强了儿科息护理. 未来的研究应该探索技术整合以提高效率和全面的患者护理文档.
科学领域:
- 护理 护理 护理
- 医疗信息学 医疗信息学
- 抚慰性护理是一种缓解性护理.
背景情况:
- 护理文档在儿科息护理中至关重要.
- 电子医疗记录 (EMR) 越来越多地用于记录.
研究的目的:
- 评估儿科息护理中EMR护理文档的当前状态.
- 确定电子护理文档的最佳实践和改进领域.
主要方法:
- 进行了范围审查.
- 利用了阿克西和奥马利的框架和乔安娜·布里格斯研究所的方法.
- 包括来自1723个记录的6项研究.
主要成果:
- 在EMR中使用电子护理文档进行评估,药物治疗,伤口护理和设备管理.
- 电子电气记录应该是用户友好的,可以进行文本搜索,并有指定的文档字段.
- 最终用户参与EMR开发提高了系统的效率和完整性.
结论:
- 电子护理文档代表了儿童息护理中的纸质方法的进步.
- 需要进一步的研究来确定具体的文档需求.
- 建议探索技术进步和人工智能集成.
相关概念视频
01:29Documentation in Long-Term and Home Healthcare Setting
994
Documentation in long-term care facilities and home healthcare settings is crucial for ensuring continuous, coordinated, and comprehensive care for patients. Each setting has its specific documentation processes and tools:
Long-Term Care Facilities
Long-Term Care Facilities
994
01:30Methods of Documentation VII: EMR
922
Electronic Medical Records (EMRs) primarily center around electronically documenting patients' health information within a single healthcare organization or practice. They contain essential clinical data related to a patient's medical history, diagnoses, medications, treatment plans, lab results, and other pertinent information relevant to the specific encounter or episode of care. EMRs are designed to streamline documentation and workflow processes within individual healthcare...
922
01:10Documentation of Nursing Diagnosis
1.3K
The nurse documents nursing diagnoses and enters them into the patient record. The identified patient's nursing diagnosis is either written out with a plan of care or entered into the electronic health record.
In some settings, data-driven computerized decision support systems are in place, allowing for more accurate nursing diagnoses. The database within one of these systems includes diagnostic labels defining characteristics, activities, and indicators for nursing. A nurse enters...
In some settings, data-driven computerized decision support systems are in place, allowing for more accurate nursing diagnoses. The database within one of these systems includes diagnostic labels defining characteristics, activities, and indicators for nursing. A nurse enters...
1.3K
01:26Guidelines for Nursing Documentation II
1.1K
Effective documentation is an integral part of nursing practice. Here are some essential guidelines to follow when documenting patient care:
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
1.1K
01:06Legal Guidelines for Documentation
1.4K
The legal guidelines for nursing documentation are essential for ensuring accurate, professional, and ethical recording of patient care. The guidelines are discussed here:
1.4K
01:08Role of Communication in the Nursing Process III: Evaluation and Documentation
1.4K
A successful patient outcome depends mainly on the evaluation stage of the nursing process. Evaluation determines effectiveness by reviewing what was done previously after the completion of nursing interventions. Every time a healthcare professional steps in or administers treatment, they must reassess or evaluate the action to ensure the intended result. During the evaluation phase, there are three probable patient outcomes:
1.4K