照护共同体叙事病历的临床应用案例与分析
Clinical application cases and analysis of narrative medical records within care community
李飞 1王剑利 2林梦岚 1郑莹 3戴晓艳 4孙晨晨 3宁晓红3
作者信息
- 1. 中国医学科学院北京协和医学院人文和社会科学学院,北京 100730
- 2. 中国社会科学院世界宗教研究所,北京 100732
- 3. 中国医学科学院北京协和医学院北京协和医院缓和医学中心,北京 100730
- 4. 中国医学科学院北京协和医学院北京协和医院国际医疗部,北京 100730
- 折叠
摘要
目的 通过呈现缓和医疗领域照护团队的叙事病历实践,在对案例进行文本分析的基础上,旨在为未来叙事内容融入现行病历的规范性、结构性提供前期基础和借鉴,确认并提升叙事病历在照护团队中系统化运用的可能.方法 选取北京协和医院缓和医疗照护团队的叙事病历案例3则并进行文本分析,阐释缓和医疗照护团队叙事病历的临床价值.3则不同案例的书写者分别为护士、社工、医生,对应的内容为会诊病历、社工服务记录和病程记录.结果 叙事病历实践呈现为系统性、共同书写与全流程书写等特征,病历中的叙事内容能够进行分类概括.结论 通过呈现照护共同体叙事病历案例与应用,再次确认叙事内容融入现行病历的可行性,并对未来医学教育的改善构成重要启示.
Abstract
Objective This study focuses on the use of narrative medical records in palliative care teams and analyzes text from cases.The goal is to establish a foundation for standardizing and structuring narrative content,providing guidance for incorporating future narratives into medical record writing.Methods Three cases of narrative medical records from the palliative care team at Peking Union Medical College Hospital were chosen for text analysis to demonstrate the clinical significance of narrative medical records within palliative care teams.These records included medical consultation records,social work service records,and disease progress records,authored by nurses,social workers,and doctors,respectively.Results Our study discovered that narrative medical records demonstrate traits such as structured writing,cooperative writing,and comprehensive documentation.Furthermore,the narrative information contained in these records can be efficiently organized and condensed.Conclusions By examining the cases and utilization of narrative medical records in the healthcare community,we emphasize the potential benefits of incorporating narrative elements into existing medical documentation.These results offer valuable insights for enhancing medical education in the future.
关键词
教育,医学/叙事/缓和照顾/照护共同体Key words
Education,medical/Narration/Palliative care/Care community引用本文复制引用
基金项目
中央高校基本科研业务费专项资金资助(3332022177)
北京协和医学院本科精品教材项目(2022zlgc0509)
国家社会科学基金后期资助项目(20FSHB002)
出版年
2024
NETL
NSTL
万方数据