摘要
在临床康复治疗中如何提高康复治疗专业学生对患者信息收集、整理、综合分析、判断、推理并去解决患者的问题能力是一直困扰我们临床实操带习教师的棘手问题。有效的治疗取决于是否有完整、精确的评估,来确定患者的功能和功能障碍。为了做出准确的评估,将ICF模式与SOAP评估记录法很好的结合,根据这个评估结果,我们拟定短期目标和长期目标,随着治疗的进展我们还会拟定患者的调整目标。治疗师设计一个治疗计划并阐明如何达到目标,然后与患者分享这个计划,随着患者情况的改善,拟定的调整目标将指导调整治疗计划;计划个体化的治疗是一个系统过程,以便为每一位患者制定出最合适的治疗,康复治疗最终目的希望能帮助每一位患者获得尽可能高的参与水平。
In clinical rehabilitation treatment,how to improve the ability of rehabilitation students to collect and sort out patients'information,analyze and judge comprehensively,reason and solve patients'problems has been a thorny problem for our clinical practice teachers.Effective treatment depends on the availability of complete,accurate assessments to determine the patient's function and dysfunction.To make accurate assessments,we use the ICF model and SOAP document.Based on this assessment,we set short-term goals and long-term goals,and we set patient adjustment goals as treatment progresses.The therapist designs a treatment plan and explains how to achieve the goal,then shares the plan with the patient.The proposed adjustment goal guides the adjustment of the treatment plan as the patient's condition changes.Planning individualized treatment is a systematic process to prescribe the most appropriate treatment for each patient.Rehabilitation ultimately hopes to help each patient achieve the highest possible level of participation.
作者
马惠
徐扬
赵艳敏
邓时万
王傲
黄维
贾程森
MA Hui;XU Yang;ZHAO Yanmin;DENG Shiwan;WANG Ao;HUANG Wei;JIA Chengsen(Department of Rehabilitation Medicine,West China Hospital,Sichuan University,Chengdu Sichuan 610041,China;Department of Rehabilitation Physical Therapy,West China School of Medical,Sichuan University,Chengdu Sichuan 610041,China)
出处
《中国继续医学教育》
2021年第8期84-87,共4页
China Continuing Medical Education
基金
四川省科技计划项目(2018FZ0114)。
关键词
ICF模式
SOAP评估记录法
康复治疗
临床思维推理
颈椎病
3E模式
教育
ICF model
SOAP evaluation record method
rehabilitation therapy
clinical thinking reasoning
cervical spondylosis
3E model
education