相关概念视频
01:08Role of Communication in the Nursing Process III: Evaluation and Documentation
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A successful patient outcome depends mainly on the evaluation stage of the nursing process. Evaluation determines effectiveness by reviewing what was done previously after the completion of nursing interventions. Every time a healthcare professional steps in or administers treatment, they must reassess or evaluate the action to ensure the intended result. During the evaluation phase, there are three probable patient outcomes:
2.1K
01:30Guidelines for Nursing Documentation I
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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.
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01:20Introduction to Documentation and Reporting
3.2K
Documentation is the systematic process of formally recording, maintaining, and communicating information.
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive...
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive...
3.2K
01:29Documentation in Long-Term and Home Healthcare Setting
1.6K
Documentation in long-term care facilities and home healthcare settings is crucial for ensuring continuous, coordinated, and comprehensive care for patients. Each setting has its specific documentation processes and tools:
Long-Term Care Facilities
Long-Term Care Facilities
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01:26Guidelines for Nursing Documentation II
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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.
1.9K
01:15Nursing Implementation
6.3K
Implementation is the execution of the nursing care plan developed during the planning phase.
The five steps to implementing effective nursing care include reassessing the patient, reviewing and revising the existing nursing care plan, organizing the resources and care delivery, anticipating and preventing complications, and implementing nursing interventions.
The five steps to implementing effective nursing care include reassessing the patient, reviewing and revising the existing nursing care plan, organizing the resources and care delivery, anticipating and preventing complications, and implementing nursing interventions.
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试点研究将自动语音识别集成到护理文档中
Keum-Sook Jeun1, Ye-Il Kim1, Myeung-Ja Lee1
1Department of Nursing, Eunpyeong St. Mary's Hospital.
Computers, informatics, nursing : CIN
|February 16, 2026
概括
这项研究开发和改进了用于护理文档的电子健康记录 (EHR) 的自动语音识别 (ASR) 系统. 代,以护士为中心的开发增强了ASR系统的功能.
科学领域:
- 医疗信息学 医疗信息学
- 医疗技术 医疗技术 医学技术
- 护理信息学 护理信息学
背景情况:
- 电子健康记录 (EHR) 对医疗保健至关重要,但护理文档仍然耗时.
- 集成自动语音识别 (ASR) 等先进技术可以简化临床工作流程.
- 优化EHR系统需要了解用户需求和代开发.
研究的目的:
- 开发和集成自动语音识别 (ASR) 技术到电子健康记录 (EHR),专门用于护理文档.
- 通过试点部署和反来评估ASR系统的有效性和用户满意度.
- 根据临床护士的反和发现的问题,代地改进ASR系统.
主要方法:
- 该研究采用了建设性电子健康评估方法 (CeHEM) 框架,分六个阶段进行.
- 一个多学科工作组合作设计,开发和实施ASR系统.
- 试点部署,临床护士采访和在线调查被用于评估和反收集.
主要成果:
- 护理ASR系统的第1版本在护理笔记和Kardex中进行了试点.
- 临床护士的反确定了系统功能和可用性的改进领域.
- 版本2重新设计,增强了功能,直观的命令和移动应用程序.
结论:
- 以护士为中心的代开发对于成功地将技术整合到医疗保健中至关重要.
- 跨学科的合作有效地将用户反转化为实际的系统改进.
- 该研究为医疗机构在EHR系统中实施ASR技术提供了宝贵的见解.