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.

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）

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.

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.

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.

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。

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.

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。

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。

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。

Hyperledger Fabric Blockchain: Secure and Efficient Solution for Electronic Health Records

Background:Electronic Health Record(EHR)systems are used as an efficient and effective technique for sharing patient’s health records among different hospitals and various other key stakeholders of the healthcare industry to achieve better diagnosis and treatment of patients globally.However,the existing EHR systems mostly lack in providing appropriate security,entrusted access control and handling privacy and secrecy issues and challenges in current hospital infrastructures.Objective:To solve this delicate problem,we propose a Blockchain-enabled Hyperledger Fabric Architecture for different EHR systems.Methodology:In our EHR blockchain system,Peer nodes from various organizations(stakeholders)create a ledger network,where channels are created to enable secure and private communication between different stakeholders on the ledger network.Individual patients and other stakeholders are identified and registered on the network by unique digital certificates issued by membership service provider(MSP)component of the fabric architecture.Results:We created and implemented different Chaincodes to handle the business logic for executing separate EHR transactions on the network.The proposed fabric architecture provides a secure,transparent and immutable mechanism to store,share and exchange EHRs in a peer-to-peer network of different healthcare stakeholders.It ensures interoperability,scalability and availability in adapting the existing EHRs for strengthening and providing an effective and secure method to integrate and manage patient records among medical institutions in the healthcare ecosystem.

Personalized E-Health Management System for Monitoring and Empowering Patients

This paper presents the design and development of a health information system following the requirements of Spanish law as well as physicians and patients. In Spain, these systems are relatively new because, until recently, ownership of patients＇ medical records belonged to the health institution. The proposed system gives patients all the information about their medical records, online. The difference from other initiatives is that the hospital provides patients with information and the latter are responsible for its future use. Importantly, this application allows physicians to carry out a personalized and individualized monitoring and treatment of each patient. The tests were conducted with real patients, all with a chronic disease （to show each patient the personalized data）. They all expressed their appreciation of this application＇s usefulness, and obtained satisfaction level was very high. Thanks to having medical information stored on the proposed system, it can be provided to other specialists to improve the knowledgement about the patient.

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.

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.

HealthyBlockchain for Global Patients

An emerging healthcare delivery model is enabling a new era of clinical care based on well-informed decision-making processes.Current healthcare information systems(HISs)fall short of adopting this model due to a conflict between information security needed to implement the new model and those already enforced locally to support traditional care models.Meanwhile,in recent times,the healthcare sector has shown a substantial interest in the potential of using blockchain technology for providing quality care to patients.No blockchain solution proposed so far has fully addressed emerging cross-organization information-sharing needs in healthcare.In this paper,we aim to study the use of blockchain in equipping struggling HISs to cope with the demands of the new healthcare delivery model,by proposing HealthyBlockchain as a granular patient-centered ledger that digitally tracks a patient’s medical transactions all along the treatment pathway to support the care teams.The patient-centered ledger is a neutral tamper-proof trail timestamp block sequence that governs distributed patient information across the decentralized discrete HISs.HealthyBlockchain connects patients,clinicians,and healthcare providers to facilitate a transparent,trustworthy,and secure supporting platform.

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.

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.

基于患者门户系统建立的个人电子健康记录和慢性病管理平台对高血压患者自我管理能力、生活质量的影响

目的 探讨基于患者门户系统(PPS)的个人电子健康记录(PHR)和慢性病管理平台对高血压患者自我管理能力、生活质量的影响。方法 选取2022年1月至2022年6月我院出院的高血压患者313例,采用随机数字表法分为研究组155例与对照组158例。对照组进行常规出院办理和随访,研究组基于PPS的PHR和慢性病管理平台进行出院办理和随访。管理3个月和6个月后比较两组的自我管理能力、生活质量、管理效果和满意度。结果 管理3、6个月后,研究组的合伙人健康量表(PIH)评分低于对照组,健康状况调查简表(SF-36)评分高于对照组(P<0.05);患者急诊和再入院次数、患者折返医院办理线下业务的次数均低于对照组(P<0.05);服药依从率81.29%高于对照组69.62%(P<0.05);并发症发生率6.45%低于对照组13.29%(P<0.05);满意度评分也高于对照组(P<0.05)。结论 基于PPS的PHR和慢性病管理平台增加高血压患者的就医便利性,提高自我管理能力,改善生活质量,慢病管理效果良好。

VTE护理风险信息化管理平台的构建及其应用效果

目的 利用信息化手段构建静脉血栓栓塞症(VTE)护理风险信息化管理平台,观察管理平台的应用效果。方法 2020年5月医院成立VTE专家组,根据《医院内静脉血栓栓塞症防治与管理建议》相关内容,利用医院医疗信息系统、电子病历系统、医学影像系统、临床检验信息系统、移动护理、医院办公系统等信息平台,建立VTE护理风险信息化管理平台,并将VTE护理风险信息化管理平台植入VTE患者电子病历中,指导护理人员工作流程。采用非同期对照试验,比较VTE护理风险信息化管理平台应用前后,外科系统住院患者VTE风险评估率、VTE发生率,以及外科系统50名护理人员VTE知识水平。结果 VTE护理风险信息化管理平台实施后,患者VTE风险评估率高于实施前,VTE发生率低于实施前,差异有统计学意义(P<0.05);50名护理人员VTE护理风险信息化管理平台实施1年后的VTE知识水平评分高于实施前,差异有统计学意义(P<0.05)。结论 VTE护理风险信息化管理平台的构建与实施有利于提高住院患者VTE风险评估率,提高护理人员对VTE知识的掌握程度及护理能力,对于针对性护理干预措施的实施,降低VTE护理风险与患者VTE发生率具有积极的促进作用。

护患沟通能力培训课程反思性教学思考与实践

目的:观察线上教学联合视频实录的反思性教学模式对低年资护士护患沟通能力培养的教学效果,为有效提升护理人员的护患沟通能力开拓新型教学模式。方法:选取福建中医药大学附属人民医院低年资护士60人为研究对象,在护患沟通能力培训中对照组采取传统授课方式,研究组采取线上教学联合视频实录的反思性教学方式;运用《护患沟通能力测评量表》和《学员自我评价表》进行教学效果评价。结果:研究组护患沟通能力测评及学员自我评价的各方面维度得分与总分都明显高于对照组,具有统计学意义(P<0.05)。结论:线上教学联合视频实录的反思性教学模式更有利于低年资护士护患沟通能力的培养,可在教学运行中推广运用。