Daniela Emilce Bonanno1, José Martín Turriani2, Paula Morra3
1Magíster en Epidemiología, Gestión y Políticas de Salud. Investigadora Adjunta. Instituto de Ciencias de la Salud, Universidad Nacional del Oeste, Argentina.. sara.ardila@psi.uba.ar.
概括
心理健康服务中的健康记录保持面临着挑战. 标准化文档和澄清自杀未遂通知数据对于改善患者护理和公共卫生政策至关重要.
科学领域:
- 医疗信息学 医疗信息学
- 心理健康服务研究 心理健康服务研究
- 公共卫生政策 公共卫生政策
背景情况:
- 健康记录对于心理健康服务至关重要,支持临床工作和公共政策.
- 然而,日常记录实践遇到重大障碍和障碍.
研究的目的:
- 分析阿根廷医院对自我伤害咨询的健康记录.
- 确定心理健康护理中需要改进的文档实践领域.
主要方法:
- 从2023年2月起对健康记录进行评估,使用检查清单评估可读性,可比性,标准化,可访问性和内容.
- 与参与机构的管理,统计和临床工作人员进行的关键信息员采访.
主要成果:
- 该研究强调需要加强文档标准化,包括预定义的领域.
- 提出了一项提案,以减少和澄清自杀未遂通知的最低数据要求.
结论:
- 加强卫生人员对记录保存的重要性的培训作为核心任务至关重要.
- 改善医疗记录实践直接有助于患者护理的质量.
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