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Characteristic of person-centered care as documented in medical records at a medical department – a mixed methods

机译：医疗部门病历中记录的以人为中心的护理特征–混合方法

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Objective: Few studies describe characteristics of content of person-centrered care (PCC) in hospital care. Therefore, this study aim to describe and compare documentation in medical records regarding content of PCC for two diagnostic groups; Chronic Obstructive Pulmonary Disease (COPD) and Chronic Heart Failure (CHF) at a medical department in a hospital in Sweden.Methods: Documentation within medical records (n = 121) regarding content of PCC (patient resources, responsibility, i.e. partnership) were analysed by a mixed methods.Results: The results describe documented healthcare activities (medical records) among patients (COPD1?= 88; CHF2?= 33) treated at medical wards practicing PCC (n = 69, 391/302) and traditional medical wards (n = 52, 491/32). The study showed limited documentation in all medical records regardless of care; however, patients with CHF have higher documentation regarding content of PCC compare to COPD in 6 (symptoms, home situation, objectives, caring activities, patients resources, continuing care) out of 7 areas (planning processes).Conclusions: To improve healthcare with limited resources, there is need to switch mind-sets from what (diagnosis) to who (resources) using all evidence (expert=scientific to expert=lived experiences) by collecting narratives to facilitate mutual health plans (partnership). This change in healthcare organisation facilitates by transformative and shared leadership to improve teamwork (health professionals, patient, relative) in partnership with all involved.
机译：目的：很少有研究描述医院护理中以人为中心护理（PCC）内容的特征。因此，本研究旨在描述和比较有关两个诊断组的PCC内容的病历文档。瑞典一家医院的医疗部门的慢性阻塞性肺疾病（COPD）和慢性心力衰竭（CHF）。方法：分析病历（n = 121）中有关PCC内容（患者资源，责任，伙伴关系）的文件结果：该结果描述了在行PCC的医疗病房（n = 69，391/302）和传统医疗病房（COPD1？= 88; CHF2？= 33）患者中记录的医疗保健活动（病历）。 n = 52，491/32）。该研究表明，所有医疗记录中的文件记录都很少，无论其护理如何。但是，CHF患者在7个领域（计划过程）中有6个（症状，家庭情况，目标，护理活动，患者资源，持续护理）的PCC含量高于COPD的文献。结论：改善有限的医疗保健资源，需要通过收集叙述以促进共同的健康计划（伙伴关系），使用所有证据（专家=科学到专家=实际经验）将思维定势从什么（诊断）切换到谁（资源）。医疗机构的这一变化促进了变革型和共享型领导的推动，从而与所有相关方合作改善了团队合作（卫生专业人员，患者，亲戚）。

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