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一项跨部门研究,研究癌症护士如何使用数字健康记录 (DHR) 来记录护理过程

Delilah Shelley¹, Phillip S Kavanagh², Deborah Davis³

¹Inpatient Haematology in Cancer Ambulatory Services, Canberra Health Services, Canberra, Australia; School of Nursing, Faculty of Health, University of Canberra, Canberra, Australia.

Seminars in oncology nursing

|November 25, 2025

概括

在癌症护理中,护士通常在数字健康记录 (DHR) 中很好地记录护理过程. 然而,整体的患者需求往往没有记录,需要注意改善护理.

科学领域:

护理信息学护理信息学
健康信息管理管理健康信息
瘤学护理护理专业

背景情况:

数字健康记录 (DHR) 在癌症护理环境中越来越多地使用.
有效的护理文档对于高质量的患者护理和连续性至关重要.
了解DHR当前的文件处理实践是必不可少的.

研究的目的:

探索护士如何使用DHR记录癌症护理环境中的护理过程.
评估DHR护理文档的完整性和质量.

主要方法:

采用了横截面研究设计.
对澳大利亚一家医疗瘤病房的20份临床护理记录进行了审计.
D-Catch仪器被用来评估DHR的护理过程中的五个要素.

主要成果:

在护理过程的大部分方面,护理文档的完整性和质量得到了很高的评分.
关于患者整体护理需求的文档特别低或不存在.
D-Catch工具对于评估护理过程文档非常有用.

结论:

虽然DHR的整体护理文档质量是积极的,但在捕捉整体护理需求方面存在差距.
需要进一步的研究来优化像D-Catch这样的工具在数字环境中的可用性.
解决整体护理方面的文档缺陷对于全面的癌症患者管理至关重要.

关键词:

癌症护理癌症护理数字健康数字健康护理文档的护理文档.护理过程护理过程.

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