在阿尔伯塔省老年患者中讨论护理指定的电子文档
Suzanne E Aronyk1, Kimberley Higgins1, Lesley Charles1
1Division of Care of the Elderly, Department of Family Medicine, University of Alberta, Edmonton, AB.
Canadian geriatrics journal : CGJ
|August 29, 2025
概括
只有不到一半的老年患者在EMR中记录了护理目标. 医疗保健提供者应优先完成这一关键的患者护理文件.
科学领域:
- 老年医学
- 医疗保健政策
- 医疗文件
背景情况:
- 护理指标 (GCD) 是临终性疾病的关键医疗指令.
- 加拿大的老龄化人口需要更新患者对维持生命护理的愿望文件.
- 增加患者的自主权强调了准确的GCD记录的重要性.
研究的目的:
- 确定老年人的护理目标 (GCD) 文件的频率.
- 分析已填写的GCD表格的设置和提供者专业.
主要方法:
- 在400名65岁以上的患者中进行了回顾性病理表.
- 在阿尔伯塔大学医院从2022年7月到2023年6月收集的数据.
- 提取了GCD文档频率,讨论设置和提供者的专长.
主要成果:
- 只有49. 3%的患者在电子病历 (EMR) 中记录了GCD.
- 在完成的356份GCD表格中,75%是在住院治疗的.
- 内部医学和家庭医学专家最常填写GCD表格.
结论:
- 只有不到一半的老年患者在省级EMR中拥有GCD文件.
- 准确的GCD文档对于患者的护理和自主性至关重要.
- 医疗保健专业人员应最大限度地利用完成基本GCD文件的机会.
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