Optimising workflow in andrology: a new electronic patient record and database

Aim： To improve workflow and usability by introduction of a new electronic patient record （EPR） and database. Methods： Establishment of an EPR based on open source technology （MySQL database and PI-IP scripting language） in a tertiary care andrology center at a university clinic. Workflow analysis, a benchmark comparing the two systems and a survey for usability and ergonomics were carried out. Results： Workflow optimizations （electronic ordering of laboratory analysis, elimination of transcription steps and automated referral letters） and the decrease in time required for data entry per patient to 71% ± 27%, P 〈 0.05, lead to a workload reduction. The benchmark showed a significant performance increase （highest with starting the respective system： 1.3 ± 0.2 s vs. 11.1 ± 0.2 s, mean ± SD）. In the survey, users rated the new system at least two ranks higher over its predecessor （P 〈 0.01） in all sub-areas. Conclusion： With further improvements, today＇s EPR can evolve to substitute paper records, saving time （and possibly costs）, supporting user satisfaction and expanding the basis for scientific evaluation when more data is electronically available. Newly introduced systems should be versatile, adaptable for users, and workflow-oriented to yield the highest benefit. If ready-made software is purchased, customization should be implemented during rollout. （Asian J Andro12006 Mar; 8： 235-241）

Under the narrative medicine theory to establish the evidence-based medical record written by doctors and patients through integrated therapy of traditional Chinese and western on digestive system diseases

Objective:The aim of this article was to discuss the theory of doctor-patient co-operated evidence-based medical record and set up the preliminary frame of the doctor-patient co-operated evidence-based medical record following the concept of narrative evidence-based medicine.Methods:The information was searched from Pubmed,Embase,CBMdisc,CNKI.A preliminary agreement was reached by referring to the principles of narrative medicine and advises given by experts of digestive system and evidence-based medicine in both Traditional Chinese Medicine and Western Medicine.Result:This research is a useful attempt to discuss the establishment of doctor-patient co-operated evidence-based medical record guided by the direction of narrative evidence-based medicine.Reflection and outlook:Doctor-patient co-operated medical record can be a key factor of the curative effect evaluation methodology system of integrated therapy of Tradition Chinese Medicine and Western Medicine on spleen and stomach diseases.

Patients with disturbances in consciousness as observed by clinical nurses: Analysis of nursing records

The objective of the present study was to discuss patients with disturbances in consciousness by analyzing nursing records. Observations from clinical nurses as well as patients’ responses about their care were selected from nursing records. Nursing records from one week of patient care were examined for patients who were unable to speak during hospitalization within a neuro-surgery ward of the hospital. Selected records were classified into the following eight categories: results from monitoring;results from observation;opening and moving the eyes to stimulus;movement of the limbs to stimulus;vocalization to stimulus;facial expression to stimulus;patient’s response to care;and miscellaneous. Patients comprised two groups. One group encompassed eight patients with Japan Coma Scale (JCS) II and the other was a group of eight patients with JCS III. When nurses use the JCS to assess patients with disturbances in consciousness, patients who awaken to stimulus are classified as JCS II, while those who do not are JCS III. The total nursing records selected for JCS II were 1551 and 1160 for JCS III. The category of “results from monitoring” was the most selected category within nursing records and accounted for 42.8% of the JCS III group, while “results from observation” accounted for 38.4% of the JCS II group. Furthermore, results indicated that the categories of “results from monitoring”, “results from observation”, and “movement of the limbs for stimulus” had peaked after two to three days, and then abruptly decreased. There were only a few records for the categories of “vocalization to stimulus” and “facial expression to stimulus”, both for the JCS II and the JCS III groups. Even though patients could not verbally indicate their intentions due to problems with consciousness, it is essential for nurses to pay careful attention to the details of patients’ reactions.

Patient's Diary Records Hospital Change

On January 27, 2012, So Chung, a Tibetan jour- nalist with Lhasa-based Tibet.cn was sent to thehospital due to a hypokalemia attack on his way to take photos in the coun- tryside during the Spring Festival. The hospital he was taken to was the People＇s Hospital of northwest China＇s Tibet Autonomous Region, where he received effective treatment and careful nursing.

Patient Participation in Communication about Treatment Decision-Making for Localized Prostate Cancer during Consultation Visits

Objectives: To describe the communication behaviors of patients and physicians and patient par-ticipation in communication about treatment decision-making during consultation visits for local-ized prostate cancer (LPCa). Methods: This is a secondary analysis of data from 52 men enrolled in the usual care control group of a randomized trial that focused on decision-making for newly diagnosed men with LPCa. We analyzed the patient-physician communication using the transcribed audio-recordings of real-time treatment consultations and a researcher-developed coding tool, including codes for communication behaviors (information giving, seeking, and clarifying/ verifying) and contents of clinical consultations (health histories, survival/mortality, treatment options, treatment impact, and treatment preferences). After qualitative content analysis, we categorized patient participation in communication about treatment-related clinical content, including “none” (content not discussed);“low” (patient listening only);“moderate” (patient providing information or asking questions);and “high” (patient providing information and asking questions). Results: Physicians mainly provided information during treatment decision consultations and patients frequently were not active participants in communication. The participation of patients with low and moderate cancer risk typically was: 1) “moderate and high” in discussing health histories;2) “low” in discussing survival/mortality;3) “low and moderate” in discussing treatment options;4) “none and low” in discussing treatment impacts;and 5) “low” in discussing treatment preferences. Conclusions: Findings suggest opportunities for increasing patient participation in communication about treatment decision-making for LPCa during clinical consultations.

Health Workers’ Documentation Process as a Prerequisite to the Integration of Patient Care at a Regional Referral Hospital in Uganda

Background: Integrated patient care is necessary for better care outcomes. Documentation enhances the integration of care;however, in the Ugandan setting, documentation of care is poor (e.g., omissions and incomplete records) and integration of patient care is not visible. This study presents a review of patient health records that was undertaken to understand documentation of care at a regional referral hospital in Eastern Uganda. This information will help in developing a documentation model to facilitate the integration of patient care in Uganda. Methodology: This retrospective review involved 513 patient health records from the medical-surgical, pediatric, and obstetric/gynecological departments of Jinja Regional Referral Hospital. Data were collected using checklists. Stratified sampling was used to capture variations in ward unit records and identify a fair representation of each department. Data were analyzed with descriptive and inferential statistics. All analyses were performed with SPSS version 22. Results: On average, the study hospital attended to 1000 patients per day and discharged 100 patients per ward unit per month. Our record review showed that documentation by both nurses and doctors was incomplete, and care was fragmented. However, doctors documented care more often than nurses, although the integration of patient care was not evident in doctors’ documentation. Conclusion: To establish integrated patient care, documentation must meet standards set by relevant professional bodies. The findings of this study will inform the development of a feasible documentation model to facilitate the integration of patient care in Uganda.

Fostering Patient Safety: Importance of Nursing Documentation

Background: Nurses are professionally accountable for assessing and documenting patients’ vital signs. Nurses failing to fulfill this responsibility position their patients at risk. This paper presents two real-life cases pertaining to patients’ safety resulting in fatal outcomes, leading to the professional, legal, and ethical liability of nurses as the providers of patient care. Objective: This paper focuses on the role of organizational culture in fostering patient safety specifically in monitoring and documentation of patients’ vital signs and early recognition of warning signs. Methodology: A comprehensive literature search was conducted using various databases, examining the significance of vital signs monitoring and documentation and early warning signs in patient safety. Relevant articles combining quantitative and qualitative data were analyzed. Results: By fostering an environment of honest reporting, healthcare organizations can enhance patient safety and improve the quality of care. This paper offers valuable insights and recommendations for developing effective strategies aligned with organizational policies and protocols. Conclusion: This paper serves as a valuable resource, encouraging healthcare professionals to reflect on their practices and the organizations to assess their contributions to creating a culture of safety. It also highlights the importance of reporting and disclosing adverse events as learning opportunities and outlines the role of ethics, professionalism, legislation, and organizational support in achieving patient safety.

Applications of Artificial Intelligence in Morocco’s Healthcare Sector: A Springboard to Medical Excellence

Artificial intelligence (AI) is revolutionizing the healthcare sector worldwide. In Morocco, several AI applications are being deployed in public and private healthcare establishments, improving appointment management, surgical operations, diagnostics, patient record tracking, biology and radiology, and OR organization. This article explores the main AI applications used in the Moroccan healthcare sector, their frequency of use, the types of establishments adopting them, as well as the main functionalities of each application and its contribution to the sector. The aim of this study is to analyze the impact of the main AI applications on quality of care and process efficiency in Moroccan healthcare facilities. This research focuses on several fundamental questions: Which AI applications are most frequently used? What types of establishments are adopting these technologies, and for which specific functionalities? What are the benefits and challenges of integrating AI into the Moroccan healthcare system, particularly in terms of territorial distribution and accessibility? The methodology is based on a quantitative analysis of data collected from selected healthcare establishments, combined with studies of reports from public health authorities and a sweep of their websites. The results show that 45% of hospitals use AI systems for appointment scheduling and 30% for medical diagnosis. The use of surgical robots, such as the Da Vinci system, increased by 30% between 2020 and 2024. Comparisons with other emerging countries highlight Morocco’s acceptable advances, while underlining the challenges, particularly in terms of the territorial distribution of these technological infrastructures generally centralized in the country’s major cities.

将叙事医学渗透到全科医学教学查房的思考

全科医学追求全人理念,十分重视将人文精神有机融入医疗过程。因此,培养全科医生、提升医学人文素养显得尤为重要。叙事医学是真正体现人文关怀和尊重患者人性的学科,有利于将人文精神融入临床实践。以上二者存在天然耦合性。文章从叙事医学视角出发,介绍了叙事医学的发展、作用及意义,分析了目前全科医学住院医师规范化培训中教学查房存在的一些问题,提出以叙事医学为专题教学查房的设想,助力解决全科医学中人文精神技能教育不足的问题,为今后将叙事医学融入全科医学人才培养体系提供参考。

Opportunities for nurses in the era of electronic health records

Nursing leaders are currently faced with opportunities to advance nursing’s role in the use of electronic health records (EHRs). Nurse leaders can advance the design of EHRs with nurse informaticists to improve health outcomes of individual and populations of patients.

Effect on Patient Safety of Brief Interventions Performed by Pharmacists via Drug Profile Books: VISualization of Treatment Assist by pharmacists (VISTA) Project in Japan

In Japanese pharmacies, Drug Profile Books (DPBs), which are a type of Personal Health Record (PHR), are incorporated in order to prevent duplicate medication and drug interactions in outpatients (patients) through the uniform management of drug administration information. In this study, we tried to clarify the effect on patient safety of brief interventions via DPBs by pharmacists. The study design was a randomized controlled trial on pharmacies as clusters. 65 pharmacies agreed to participate in the study (intervention group (IG): 33;control group (CG): 32). The primary outcomes were: rate of inquiry occurrence, rate of prescription change, and rates of duplicate medications & drug interactions. 56 pharmacies (IG: 29;CG: 27) completed the study. There was a higher tendency for prescription changes in the IG compared to the CG (IG: 0.03%;CG: 0.02%;P = 0.08). In addition, the rate of duplicate medications & drug interactions accounting for the inquiries was significantly higher in the IG than in the CG (IG: 89.2%;CG: 71.9%;P = 0.01). This implied that brief interventions by pharmacists using DPBs had an effect in raising patient safety.

胰腺癌住院患者围手术期营养相关症状自我报告与护理记录一致性研究

目的调查并探讨胰腺癌患者围手术期对自身营养相关症状自我报告与护理记录之间的一致性。方法采用便利抽样法,选取2022年1月至2022年12月某肿瘤专科医院(三甲医院)胰腺癌行手术治疗的患者90例。在术前、术后出院前分别采用调查问卷形式收集患者一般资料、自身营养相关症状自我报告等资料,与医院病历系统护理记录中患者营养情况相关内容进行比较,采用Kappa检验分析患者自我报告与护理记录的一致性。结果术前患者自我报告食欲降低、进食量减少、恶心呕吐、肌力减退、体重减轻(连续性)、乏力、腹胀的发生率均明显高于护理记录(P<0.05),仅是否发生腹泻一项与护理记录一致性较好,其他项目如恶心呕吐、乏力、进食量减少、白蛋白是否正常知晓情况等与护理记录一致性均较差;术后出院前患者自我报告的食欲降低、进食量减少、恶心呕吐、肌力减退、体重减轻(连续性)、乏力、腹胀的发生率均明显高于护理记录(P<0.05),与护理记录一致性较差。结论在术前、术后出院前两个时间点,胰腺癌围手术期患者对自身营养相关症状的自我报告与护理记录存在不一致的现象,护理记录存在低估营养相关症状发生率的情况,影响NRS2002营养风险评分及患者主观整体营养相关症状评量表评分准确性,导致不能早期及时发现患者存在营养不良的风险或营养不良,导致营养支持治疗的延迟或延误影响术后康复。故应重视患者自我报告,将自我报告内容作为护理观察、评估的来源。

患者门户在老年认知障碍患者中的应用进展

基于患者门户的信息共享有助于满足老年认知障碍患者在疾病护理方面的独特需求。文章从患者门户概述、发展现状、可行性及效果、应用困境进行介绍与分析,并提出思考与对策,以期为患者门户在国内老年认知障碍患者中的应用提供新思路,为完善我国本土化的信息共享平台建设提供参考。

电子病历应用与患者隐私保护的冲突与调适

载有患者隐私信息的电子病历在推广应用中时有泄露而造成负面影响,有必要分别从其书写、存储和保管、使用及封存等运行环节,就其隐私泄露隐患、隐私保护规范缺失、使用监管不足及保护意识不够等风险问题一一予以讨论,剖析其原因,并从医疗机构外部和内部探求双重保护路径,以提升其应用中对患者隐私保护的力度和效果。

某三级医院危重患者住院病历质量分析

目的对某院危重患者住院病历进行抽查,将结果进行分类汇总,分析存在的问题,究其原因,寻求提升病历书写质量的措施。方法从某院2022年12月1日—2023年11月30日出院的1117份危重患者住院病历中抽取330份。依据《病历书写基本规范(2010版)》《医疗质量安全核心制度要点》《住院病案首页数据填写质量规范(暂行)》的相关规定及要求,结合医院实际情况对所抽查危重患者住院病历进行质控。结果抽查的330份危重患者住院病历中,有缺陷的病历占45.15%,其中病历首页信息存缺陷率最高,达到56.38%;其次为病程记录缺陷,缺陷率达25.50%。在缺陷率最高的病历首页项目中,存在缺陷最多的是首页基本信息的漏填、错填,占总病历首页信息缺陷份数的28.57%;其次是转科科别漏填,占总病历首页信息缺陷份数的11.90%;重症监护室记录的填写缺陷与主要诊断选择错误占比相持平,达10.71%。结论危重患者住院病历缺陷内容集中在病历首页信息、病程记录、出院(死亡)记录、知情同意书、授权委托书上,科室之前缺陷率有一定差距,建议通过强化医师法律意识、优化信息系统功能、增强科室间的协调、加强病历书写培训力度、实行奖惩责任追究,加强对危重患者住院病历质量的管理,提升病历整体质量。

叙事医学融入妇产科教学查房的探索与体会

叙事医学是一种为患者提供尊重、共情和人性化医疗照护的医疗模式。在妇产科教学查房过程中融入叙事医学教学理念,从准备工作到教学过程,分步骤实施,有效提高了住院医师的医患沟通能力,推动医患共同决策,制订出最合适的诊疗方案,同时也增强了医者人文素质和社会责任感。

PROMIS在成人造口患者随访管理中的应用价值研究进展

大数据时代,患者的管理逐渐转变为理论驱动与数据驱动相结合,实时监测患者动态变化的健康结局数据。患者报告结局电子化实施路径内容无需他人解释,为解决患者随访管理中的信息延续问题提供了新思路,其对实现患者持久、动态、实时的健康状态监测发挥巨大优势,在造口患者的延续性管理中具有实用性。本文就患者报告结局测量信息系统(patient-reported outcomes measurement information system,PROMIS)和随访管理的概念、造口相关PROMIS评估工具、数据采集方式、应用价值进行综述,以期为我国开展造口患者随访管理提供参考借鉴。

基于患者就医行为的眼病智慧医疗服务策略研究

目的/意义了解眼病患者就医行为特征,优化眼病智慧医疗服务策略。方法/过程以安德森医疗服务利用模型为指导,调取某医院17 602人次的眼科电子病历数据,采用卡方检验和谱系聚类方法从4个维度挖掘眼病患者的就医行为特征;调查其中702例眼病患者对智慧医疗服务的满意度,通过有序logistic回归分析主要影响因素。结果/结论根据眼病患者人口学特征、挂号方式、眼科常见疾病与发病数据、结算方式等特征,从资源布局、技术兼容、服务模式和优化结算4方面提出眼病智慧医疗服务建议与策略。

创伤死亡不同血糖水平患者存活时间、感染率和MODS发生率病历调查

目的研究创伤死亡不同血糖水平患者院前创伤评分(revised traum a score,RTC;glasgow com a scale,GCS)、3 d后死亡构成比、感染率和多器官功能不全综合征(mu ltipe organ dysfunction syndrom e,MODS)发生率的变化。方法随机抽查本院1999年1月至2005年1月455份住院创伤死亡病历,根据空腹血糖水平及正常参考范围分为创伤死亡正常血糖组57例和创伤死亡高血糖组298例。统计创伤死亡不同血糖水平组RTC、GCS、3 d后死亡构成比、感染率和MODS发生率及的变化,并计算创伤死亡患者血糖与MODS相关定量指标的相关系数。结果①创伤死亡高血糖组RTC为6.31±1.04,GCS为4.23±0.52;创伤死亡正常血糖组RTC为4.43±0.22,GCS为2.21±0.34。创伤死亡高血糖组院前创伤评分明显高于创伤死亡组正常血糖(P<0.01)。②创伤死亡高血糖组3 d后死亡构成比为67.34%,创伤死亡正常血糖组3 d后死亡构成比为17.54%。创伤死亡高血糖组3 d后死亡构成比明显高于创伤死亡正常血糖组(P<0.01)。③创伤死亡高血糖组感染率为83.92%,MODS发生率为71.86%;创伤死亡正常血糖组感染率为21.05%,MODS发生率为10.53%。创伤死亡高血糖组感染率和MODS发生率均明显高于创伤死亡正常血糖组(P<0.01)。④455例创伤死亡患者血糖水平与血ALT、AST、BUN、CRE、PCO2、CK明显正相关(P值均<0.01)。结论创伤死亡高血糖患者院内存活时间长,感染率和MODS发生率高。创伤死亡正常血糖患者伤情重,存活时间短,感染率和MODS发生率低。创伤高血糖患者死亡因素以感染和MODS为主,创伤正常血糖患者死亡因素以非MODS因素(大出血和颅脑直接损伤等)为主。创伤血糖水平升高可作为创伤MODS预警指标,但血糖正常预后也不一定好。

一种区域医疗信息一体化模型研究

为了实现区域医疗信息的数据交换与共享,采用基于HL7标准的电子病历系统进行设计,同时借助消息的中间件技术建立公共接口。根据现状分析医院内部与跨院数据处理需求,利用不同HL7标准接口引擎方式实现数据标准化传输,结合中间件技术设计区域医疗信息一体化模型的结构功能,实现了不同平台下区域医疗信息一体化数据的查询和共享,理论与实践证明模型的设计是可行的。