临床文档反映了家长和临床医生如何分享关于手术的决定吗?
Angele Kelly1, Dalia Mitchell2, Anne R Links1
1Johns Hopkins Medicine.
Research square
|November 24, 2025
概括
父母在儿科手术方面的担忧和偏好往往没有被记录下来. 改善家庭观点的记录可以提高沟通和以患者为中心的护理.
科学领域:
- 儿科手术 儿科手术
- 卫生沟通健康沟通
- 共享的决策方式
背景情况:
- 共享决策 (SDM) 在临床实践中被广泛接受.
- 临床文档中SDM核心元素的反映仍然不清楚.
- 这种差距在儿科手术中至关重要,父母作为代理决策者.
研究的目的:
- 分析家长的担忧和偏好如何反映在儿科手术接触期间的临床文档中.
- 评估这些元素在口头沟通中的频率,内容和时间,与医疗记录对比.
主要方法:
- 转录的音频录制的门诊病人的分析,用于儿科外科评估.
- 访问记录和相应的医疗文件的编码,以满足家长的担忧和偏好.
- 对 SDM 的表达元素进行口头沟通和书面记录的评估.
主要成果:
- 近一半的接触涉及讨论家长的担忧 (42%) 和偏好 (45%).
- 关注点集中在症状上,并在整个访问中提出;偏好集中在治疗决策上,通常在访问后面.
- 大约一半的独特担忧 (46%) 和偏好 (49%) 记录在医疗记录中.
结论:
- 在儿科手术会议上讨论的家长的担忧和偏好往往被遗漏在临床文档中.
- 对家庭观点的一致记录可以提高透明度和沟通.
- 改进的文档支持高质量的,以患者和家庭为中心的护理.
相关概念视频
Methods of Documentation VI: Case Management Model
839
The case management model is a multidisciplinary approach that involves healthcare professionals from diverse disciplines, such as physicians, nurses, therapists, social workers, and pharmacists, working collaboratively to address the various needs of patients. Each healthcare professional brings unique expertise and perspectives, contributing to a more comprehensive understanding of the patient's condition and tailoring treatment plans accordingly.
For example, a patient with a chronic...
For example, a patient with a chronic...
839
Legal Guidelines for Documentation
1.9K
The legal guidelines for nursing documentation are essential for ensuring accurate, professional, and ethical recording of patient care. The guidelines are discussed here:
1.9K
Methods of Documentation IV: Focus Charting
1.6K
Focus Charting, also known as the focus charting system or "focus documentation," is a systematic documentation approach used in healthcare to organize patient information in medical records.
It typically involves three columns for recording information:
It typically involves three columns for recording information:
1.6K
Guidelines for Nursing Documentation I
1.7K
Quality documentation and reporting share essential characteristics that ensure they are practical and valuable resources for those who use them. These characteristics are:
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
1.7K
Psychosurgery
1.3K
Psychosurgery, the surgical alteration or permanent removal of brain tissue to alleviate severe psychological conditions, stands as one of the most radical and controversial treatments in the history of mental health care. Its development and application have evolved significantly, marked by dramatic shifts in scientific understanding and ethical perspectives.
Historical Development of Psychosurgery
In the 1930s, Portuguese neurologist Antonio Egas Moniz introduced a surgical procedure designed...
Historical Development of Psychosurgery
In the 1930s, Portuguese neurologist Antonio Egas Moniz introduced a surgical procedure designed...
1.3K
Guidelines for Nursing Documentation II
1.5K
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.
1.5K


