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相关概念视频

Methods of Documentation VII: EMR01:30

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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...
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Nursing Clinical Information System (NCIS)
A Nursing Clinical Information System (NCIS) is a specialized type of healthcare information system tailored to meet the unique needs of nursing practice. It incorporates the principles of nursing informatics to streamline information management and improve the quality of care delivery.
Critical attributes of NCIS include:
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Following these guidelines can help nurses accurately measure vital signs, assess changes in patient conditions, and provide timely treatment when necessary. Adhering closely to the guidelines ensures the accuracy and reliability of the results.
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使用电子临床笔记测量符合目标的护理

Catherine L Auriemma1,2,3,4, Anne Song2,3,4, Lake Walsh5

  • 1Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, Philadelphia.

JAMA network open
|July 3, 2025
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概括
此摘要是机器生成的。

在严重疾病中衡量符合目标的护理 (GCC) 是至关重要的. 这项研究表明,临床笔记可以可靠地评估GCC,为研究和质量改进的自动化方法铺平了道路.

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科学领域:

  • 严重疾病护理 严重疾病护理
  • 抚慰性护理研究研究
  • 临床信息学是一种临床信息学.

背景情况:

  • 符合目标的护理 (GCC) 是严重疾病护理质量的黄金标准.
  • 现有的测量GCC的方法对于广泛的研究是不切实际的.
  • 精确的GCC测量对于改善患者的治疗结果至关重要.

研究的目的:

  • 开发和验证一种仅使用临床笔记测量GCC的方法.
  • 评估使用追溯医疗记录审查用于GCC评估的可行性.
  • 为严重疾病研究和质量改善建立可靠的方法.

主要方法:

  • 在3个城市医院对109名严重病患的成年人进行了回顾性队列研究.
  • 独立的临床医生对临床笔记的审查,以根据记录的护理目标对护理时代进行分类.
  • 将其分为4类:以舒适为重点,以功能为导向,延长寿命或不清楚.

主要成果:

  • 对于分类所收到的护理而言,具有很高的interrater可靠性 (Cohen κ = 0.92).
  • 50%的护理时代被归类为符合目标的.
  • 在6个月的随访期间,78%的患者经历了不确定的一致性,39%的患者经历了目标不一致的护理.

结论:

  • 仅仅通过临床笔记可以可靠地测量重病患者的目标一致护理.
  • 该方法支持在研究和质量倡议中实用和可扩展地测量GCC.
  • 这些发现鼓励开发GCC的自动化,基于文本的分类系统.