在开放笔记的时代,教育医疗学员关于以患者为中心的文档
Elizabeth A Fleming1, Nyla E Mathis2, Magnolia J Larson3
1Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin Liz.Fleming@fammed.wisc.edu.
Annals of family medicine
|January 26, 2026
概括
开放注释将临床文档转化为患者沟通. 在以患者为中心的文档中培训医学学生可以增强同情心,减少偏见,并加强患者与医生的关系,以获得更好的护理.
科学领域:
- 医学教育 医学教育
- 卫生沟通健康沟通
- 数字健康数字健康
背景情况:
- 开放注释允许患者直接访问电子健康记录中的临床文档.
- 这将文档从行政用途转移到直接与患者沟通.
- 以关系为中心的护理强调了患者,临床医生和护理团队之间的互动质量.
研究的目的:
- 突出临床文档语言和语调在以关系为中心的护理中的重要性.
- 倡导培训医疗专业学生以患者为中心的文档.
- 强调文档对患者与医生的关系和患者体验的影响.
主要方法:
- 分析临床文档在采用开放注释的过程中不断变化的作用.
- 检查以关系为中心的护理原则及其对文档的含义.
- 讨论临床笔记中语言和语调对患者参与和治疗联盟的影响.
主要成果:
- 临床文档现在是患者沟通的一种形式,影响了患者与医生的关系.
- 包容,尊重的文档加强了治疗联盟,并肯定了患者的角色.
- 偏见或判断性语言可能会破坏人际关系,并对健康结果产生负面影响.
结论:
- 以患者为中心的文档对于推进以关系为中心的护理至关重要.
- 对于健康专业学生来说,对同情,公正的文档的培训是必不可少的.
- 有效的文档改善了患者和临床医生的体验,并加强了治疗联盟.
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