Theodorou Maria E, Henschen Bruce L, Chapman Margaret
Jt Comm J Qual Patient Saf. 2020 Apr;46(4):217-226. doi: 10.1016/j.jcjq.2020.01.002. Epub 2020 Jan 18.
Comprehensive care plans are dynamic documents maintained by an interdisciplinary team that contain specific, actionable information for clinicians and staff across multiple care settings. They promote communication and continuity of care by suggesting communication strategies, medical plans, and psychosocial resources. This article describes the structure and development process of comprehensive care plans for frequently hospitalized patients enrolled in a program designed to improve care for this vulnerable population. These care plans are widely used, with inpatient physicians referring to the care plan in their notes during 92.0% of admissions.
综合护理计划是由跨学科团队维护的动态文件，其中包含针对多个护理环境中的临床医生和工作人员的具体、可操作的信息。它们通过建议沟通策略、医疗计划和心理社会资源来促进护理的沟通和连续性。本文描述了针对参加旨在改善对这一弱势群体护理的项目的频繁住院患者的综合护理计划的结构和制定过程。这些护理计划被广泛使用，92.0%的住院患者在入院时，住院医生会在病历中参考护理计划。
