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Updated: Sep 11, 2025

Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care

Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care

Published on: February 16, 2011

评估在护理目标中对积极和消极内容的看法注意事项

Gina M Piscitello¹, Emiliano Garcia-Fuentes², Robert M Arnold³

¹Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania; Palliative Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania.

Journal of pain and symptom management

|August 13, 2025

概括

社区成员和临床医生对什么构成护理目标对话 (GOCC) 注释中的负面内容存在分歧. 了解这些不同的看法是改善患者和家人的文档的关键.

科学领域:

医疗文件医疗文件
以患者为中心的沟通
健康差异在健康上的差异

背景情况:

电子健康记录 (EHR) 中负面内容的临床记录是一个公认的问题.
医疗目标对话 (GOCC) 笔记对于记录患者愿望至关重要.

研究的目的:

评估社区成员和临床医生对GOCC笔记中负面内容的看法.
发现这些重要文件中构成负面内容的理解中的差异.

主要方法:

这是一项混合方法研究,涉及14家医院的12名参与者 (6名社区成员,6名临床医生).
用专题分析来分析65个GOCC笔记中的正面,中立和负面内容的感知.

主要成果:

两组人都同意积极的内容 (例如,善良的语言,患者价值观).
关于负面内容出现了显著的差异:社区成员提到理解局限性,健康状况不佳的描述和缺乏同情心.
临床医生将写作不佳,信息缺失和判断性描述视为负面内容.

结论:

社区成员和临床医生之间对于什么构成GOCC笔记中的负面内容的共识很低.
调查结果强调需要更明确的指导方针,以改善GOCC对所有利益相关者的笔记文档.
改进的文档可以加强医疗保健中的沟通和共享决策.

关键词:

电子健康记录文件电子健康记录文件关怀的目标关怀的目标负面内容的负面内容严重的疾病严重的疾病.

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