一个便携式医疗记录系统用于老年人
JAMA
|July 6, 1979
概括
一个便携式医疗记录系统,包括手和钱包卡,对于患有慢性疾病的老年患者来说非常有用. 与社区护理相比,医生在医院门诊机构中更经常注意到该系统.
科学领域:
- 老年病的医生 老年病的医生
- 医疗信息学 医疗信息学
- 患者安全 患者安全
背景情况:
- 患有慢性疾病的老年患者通常需要持续的医疗管理.
- 有效地沟通患者的医疗信息对于护理的连续性至关重要.
- 便携式医疗记录系统旨在提高患者数据的可访问性.
研究的目的:
- 评估一个便携式医疗记录系统 (手和钱包卡) 的实用性,用于门诊,慢性病患者,老年患者.
- 为了比较不同医疗保健机构的医生对该系统的认可率.
主要方法:
- 为两组患有慢性疾病的老年患者提供了一个便携式医疗记录系统.
- 组1:23名从熟练护理机构出院的患者进入社区护理.
- 第二组:24名患者正在一家急性普通教学医院的门诊病房.
- 每两周一次的后续电话和医生讨论评估了系统的有用性.
主要成果:
- 医生在46%的患者访问中注意到手,28%的患者访问中注意到钱包卡.
- 第二组医生 (门诊部) 比第一组医生 (社区护理) 更频繁地识别了该系统.
- 该系统在非紧急医疗保健遭遇中证明了它的实用性.
结论:
- 便携式医疗记录系统对于治疗慢性疾病的老年患者有好处.
- 医疗保健环境对这些系统的可见性和认可产生重大影响.
- 需要进一步的研究来优化对老年人的便携式医疗记录的设计和实施.
相关概念视频
01:11Purpose of Health Records I
The vital purpose of health records is to provide a complete and accurate account of a patient's medical history, including communication, diagnostic and therapeutic orders, care planning, research, and quality review.
Here's a breakdown of how health records serve these purposes:
Here's a breakdown of how health records serve these purposes:
01:19Purpose of Health Records II
Health records serve various essential purposes in the healthcare system. Here are some key purposes:
01:18Methods of Documentation I: Source-Oriented Records
Source-oriented records, or SOR, are medical record-keeping organized by the data source. The SOR system was first developed in the mid-1900s to organize the growing patient data in hospitals and other healthcare facilities.
In an SOR, each discipline involved in patient care maintains a separate medical record section. This record-keeping method enables easy tracking of patient progress and ensures healthcare staff have access to up-to-date information.
Key Attributes include the following:
In an SOR, each discipline involved in patient care maintains a separate medical record section. This record-keeping method enables easy tracking of patient progress and ensures healthcare staff have access to up-to-date information.
Key Attributes include the following:
01:26Methods of Documentation II: POMR
The Problem-Oriented Medical Record (POMR) revolutionized medical record-keeping by introducing a systematic approach focusing on the patient's problems rather than merely listing symptoms. Dr. Lawrence Weed's introduction of this method in the 1960s marked a significant advancement in medical documentation. The POMR framework consists of four key components: the database, problem list, plan of care, and progress notes.
01:30Methods of Documentation VII: EMR
Electronic Medical Records (EMRs) primarily center around electronically documenting patients' health information within a single healthcare organization or practice. They contain essential clinical data related to a patient's medical history, diagnoses, medications, treatment plans, lab results, and other pertinent information relevant to the specific encounter or episode of care. EMRs are designed to streamline documentation and workflow processes within individual healthcare settings,...
01:29Documentation in Long-Term and Home Healthcare Setting
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