Momwe Mungalembere Zolemba Zolondola Zachipatala
Zolemba zachipatala ndi zikalata zofunika kwambiri zomwe zimagwiritsidwa ntchito ngati maziko olumikizirana pakati pa akatswiri azaumoyo, zida zowunikira zachipatala, umboni wazamalamulo, komanso njira yayikulu yopitirizira chisamaliro cha odwala. Zolemba zolondola zimathandiza madokotala, anamwino, akatswiri a zamankhwala, ndi akatswiri ena azaumoyo kumvetsetsa bwino matenda a wodwala, kuchepetsa chiopsezo cha zolakwika zachipatala, ndikukweza mtundu wa chisamaliro. Mosiyana ndi zimenezi, zolemba zosakwanira kapena zosamveka bwino zingayambitse kutanthauzira molakwika, kuchedwa kwa chithandizo, komanso nkhani zamalamulo. Chifukwa chake, kukonza zolemba zachipatala zolondola si ntchito yoyang'anira yokha, koma gawo lofunika kwambiri pakuchita bwino kwachipatala.
1. Kumvetsetsa cholinga ndi mfundo zoyambira za zolemba zachipatala
Musanalembe, mvetsetsani kuti zolemba zachipatala cholinga chake ndi kulemba mfundo zachipatala: madandaulo a wodwalayo, zomwe wapeza pofufuza, matenda ogwira ntchito, dongosolo la chithandizo, ndi momwe angayankhire chithandizocho. Mfundo zazikulu ndi kulondola, kukwanira, kumveka bwino, nthawi, ndi kutsatizana. Zolemba ziyenera kuwonetsa njira yoganizira zachipatala komanso chifukwa chopangira zisankho. Kuphatikiza apo, zolemba ziyenera kusunga chinsinsi cha wodwala ndikutsatira miyezo ya malo ochitirako ntchito ndi malamulo oyenera.
Mfundo ina yofunika ndi kusayang'ana mbali zonse. Pewani malingaliro osafunikira kapena omwe angakhale okondera. Mwachitsanzo, m'malo molemba kuti "wodwalayo anali wouma mtima," lembani kuti "wodwalayo anati sanamwe mankhwala ake kwa masiku atatu chifukwa amaona kuti zizindikiro zake zikuchepa." Mawu amtunduwu ndi oona, osaweruza, komanso othandiza pokonzekera maphunziro.
2. Gwiritsani ntchito mawonekedwe okonzedwa bwino (SOAP/ADIME)
Kulondola ndi kuŵerenga bwino kumawonjezeka pamene zolemba zapangidwa mu mtundu wamba. Mitundu iwiri yomwe imagwiritsidwa ntchito kwambiri ndi iyi:
- SOAP: Kuganizira, Cholinga, Kuyesa, Ndondomeko
– ADIME (nthawi zambiri mu zakudya/unamwino): Kuwunika, Kuzindikira, Kulowererapo, Kuyang'anira, Kuwunika
Kawirikawiri, SOAP imagwiritsidwa ntchito nthawi zambiri chifukwa ndi yachidule komanso yokhazikika. Ndi SOAP, chidziwitso chofunikira sichimatayika ndipo n'chosavuta kuchiwunikira.
S — Yogwirizana ndi maganizo a munthu
Gawoli lili ndi madandaulo akuluakulu komanso mbiri yakale kuchokera pamalingaliro a wodwalayo. Phatikizanipo:
– Madandaulo akuluakulu okhala ndi nthawi ("kupweteka pachifuwa kuyambira maola awiri").
- Mbiri ya matenda omwe alipo: chiyambi, malo, khalidwe, mphamvu, zinthu zomwe zimachepetsa/zikukulitsa, zizindikiro zomwe zikugwirizana nawo.
- Mbiri yakale yachipatala, ziwengo, mankhwala omwe akumwedwa panopa, mbiri ya banja, chikhalidwe cha anthu (kusuta/mowa), ndi zinthu zina zomwe zimayambitsa chiopsezo.
Lankhulani momveka bwino, kuphatikizapo mawu ofotokozera mwachindunji ngati pakufunika kutero. Mwachitsanzo, wodwala akunena kuti, “Ndimamva kupuma movutikira ndikakwera masitepe.”
O — Cholinga
Lili ndi deta yomwe ingayesedwe kapena kuwonedwa, mwachitsanzo:
- Zizindikiro zofunika kwambiri: kuthamanga kwa magazi, kugunda kwa mtima, kutentha, kuthamanga kwa mpweya, komanso kuchuluka kwa madzi m'thupi.
- Kuwunika thupi mwadongosolo.
- Zotsatira zothandizira: labu, radiology, ECG, ndi zina zotero.
- Yang'anirani khalidwe loyenera (monga kusakhazikika, kuoneka ngati watopa kupuma).
Onetsetsani kuti manambala ndi mayunitsi ndi olondola. Ngati pali zochita zilizonse, lembaninso nthawi ndi zotsatira zake. Zolemba za cholinga ziyenera kukonzedwa bwino, mwachitsanzo, kuyambira kumutu mpaka kumapazi kapena pogwiritsa ntchito ziwalo.
A — Kuyesa
Mu gawoli, wopereka chithandizo chamankhwala akufotokoza mwachidule zomwe zapezeka: kuzindikira matenda, kusiyana kwa matenda, kuopsa kwake, ndi vuto lalikulu lachipatala. Kuwunikaku kuyenera kufotokoza ubale womwe ulipo pakati pa deta yochokera kwa munthu ndi yolondola komanso mfundo zake zachipatala. Mwachitsanzo: "Kupweteka pachifuwa ndi kofala kwa angina, zinthu zomwe zimayambitsa matenda ndi kuthamanga kwa magazi ndi kusuta fodya, ndipo ECG ikuwonetsa kuvutika maganizo kwa ST."
Ngati matenda enieni sanapezeke, lembani mawu akuti “wokayikira” kapena “n’zotheka” ndipo fotokozani chifukwa chake. Kuona mtima kwachipatala n’kofunika: musalembe ngati kuti ndi otsimikizika pamene palibe umboni wokwanira.
P — Ndondomeko (Ndondomeko)
Gawo la "Ndondomeko" likufotokoza zomwe zidzachitike, kuphatikizapo:
- Kuwunika kwina komwe kukukonzekera.
– Chithandizo cha mankhwala (dzina, mlingo, kuchuluka kwa mankhwala, njira, nthawi yogwiritsira ntchito).
- Zochita (monga nebulization, IV insertion).
- Kukonzekera uphungu/kutumiza uthenga.
– Maphunziro: zakudya, masewera olimbitsa thupi, zizindikiro zoopsa.
- Kutsatira: nthawi yolamulira, magawo amayang'aniridwa.
Mapulani ayenera kukhala olunjika komanso otheka kuwakwaniritsa. Pewani mapulani ochulukirapo monga "zoyang'anira" popanda magawo omveka bwino.
3. Onetsetsani kuti nthawi ndi nthawi zikuyendera bwino
Zolemba zachipatala ziyenera kulembedwa nthawi yomweyo mutakumana ndi dokotala, osati maola angapo pambuyo pake, kuti musaiwale mfundo zofunika. Lembani tsiku ndi nthawi nthawi zonse. Kuwerengera nthawi ndikofunikira kwambiri pazochitika zadzidzidzi, kusintha kwadzidzidzi kwa mkhalidwe, kapena kugonekedwa m'chipatala. Ngati pali chochitika chachikulu (monga kuchepa kwa kuthamanga kwa magazi, kusamvana ndi mankhwala), lembani nthawi ya chochitikacho, chithandizo chomwe chachitika, ndi momwe wodwalayo wachitira.
Ngati kukonza kuli kofunikira, tsatirani njira: musafufute popanda kutchula. Mu makina a mapepala, izi nthawi zambiri zimachitika podutsa mzere umodzi, kulemba zilembo zoyambira, tsiku/nthawi ya kukonza, ndikulemba kukonza. Makina amagetsi nthawi zambiri amakhala ndi njira yodziwira yokha.
4. Gwiritsani ntchito chilankhulo chomveka bwino komanso chokhazikika
Kulondola sikuti kungonena za kukhala wolondola, komanso kukhala womveka bwino. Gwiritsani ntchito mawu odziwika bwino azachipatala ndipo pewani mawu ofupikitsa omwe angatanthauzidwe mosiyana. Ngati chipatala chanu chili ndi mndandanda wa mawu ofupikitsa ovomerezeka, tsatirani mndandandawo. Mwachitsanzo, mawu ena ofupikitsa, monga "OD," angatanthauze "kamodzi patsiku" kapena "diso lamanja," kutengera ndi nkhaniyo. Ngati pali chisokonezo, lembani zonse.
Kupatula apo:
- Pewani ziganizo zazitali komanso zodzaza ndi mawu.
- Gwiritsani ntchito mfundo zofunika kulemba zotsatira za mayeso.
- Onetsetsani kuti zolemba zake zikuwerengedwa bwino (ngati zili pamanja).
Zolemba zabwino zimathandiza kuti ogwira ntchito zachipatala ena amvetse bwino vutoli mumphindi zochepa chabe, makamaka panthawi yopereka chithandizo kapena usiku.
5. Lembani zambiri za mankhwala osokoneza bongo mosamala
Zolakwika pa mankhwala nthawi zambiri zimachitika chifukwa cha zikalata zosamveka bwino. Mukamalemba mankhwala, onetsetsani kuti mwalemba izi:
– Dzina la mankhwala (ndi bwino kugwiritsa ntchito dzina lodziwika bwino nthawi iliyonse ikatheka).
- Mlingo ndi mayunitsi (mg, mcg, IU).
- Njira (pakamwa, m'mitsempha, m'mimba, m'mapapo).
- Kuchuluka kwa mankhwalawa ndi nthawi yoperekera mankhwalawa.
- Zizindikiro (makamaka za mankhwala a "prn"/pamene pakufunika).
- Mayankho, zotsatirapo zake, ndi ziwengo.
Ngati mwasintha njira yochizira (monga kusiya kumwa mankhwala), lembani chifukwa chake. Izi zithandiza kuwunika kwachipatala ndikuletsa kubwereranso kwa mankhwalawo mwangozi.
6. Lembani chilolezo chodziwitsidwa ndi maphunziro
Zolemba zolondola zachipatala sizimangokhala ndi deta yachipatala komanso njira yolankhulirana. Ngati njira ikufunika chilolezo, lembani kuti wodwala/banja lalandira kufotokozera za matenda, ubwino ndi zoopsa, njira zina, ndi zotsatirapo za kukana njirayo. Lembaninso zotsatira zake: chilolezo kapena kukana, ndi amene anasaina.
Maphunziro a odwala ayeneranso kulembedwa, makamaka pa matenda osatha komanso kugwiritsa ntchito mankhwala. Mwachitsanzo: "Maphunziro a njira zopumira, wodwalayo adatha kubwereza chiwonetserocho molondola." Zolemba izi ndizofunikira kuti chisamaliro chipitirize komanso nkhani zamalamulo.
7. Sungani chinsinsi ndi chitetezo cha deta
Zolemba zachipatala ndi zachinsinsi. Onetsetsani kuti anthu ovomerezeka ndi okhawo omwe angapezeke. Pa makina apakompyuta, gwiritsani ntchito akaunti yanu, musagawane mawu achinsinsi, ndipo nthawi zonse tulukani mukamaliza. Makina osindikizira amafunikanso chisamaliro: musasiye zosindikizidwa m'malo opezeka anthu ambiri. Pa zokambirana, pewani kutchula za wodwalayo m'malo opezeka anthu ambiri kapena pa malo ochezera a pa Intaneti. Kusunga chinsinsi mokwanira ndi gawo la ukatswiri.
8. Chitani kafukufuku ndikuwunikanso zizolowezi
Kuti muwongolere bwino zolemba zanu, khalani ndi chizolowezi chowunikira mwachangu musanamalize kulemba zolemba zanu:
- Kodi madandaulo akuluakulu ndi nthawi yake zalembedwa?
- Kodi zizindikiro za moyo zili bwino?
- Kodi matenda/kuwunika kukugwirizana ndi zomwe zapezeka?
- Kodi dongosololi ndi lomveka bwino, kuphatikizapo kutsatira?
- Kodi mankhwala ali ndi mlingo ndi njira yogwiritsira ntchito?
- Kodi pali ziwengo zilizonse zomwe zapezeka?
Zipatala nthawi zambiri zimachita ma audit amkati. Amaona ma audit ngati mwayi wowongolera, osati kungoyesa chabe. Ubwino wa zolemba zachipatala umasonyeza ubwino wa njira zachipatala.
Mapeto
Kupanga zolemba zachipatala zolondola kumafuna kulondola, kapangidwe, ndi kasamalidwe ka nthawi. Ndi mawonekedwe okhazikika monga SOAP, chilankhulo chomveka bwino, kulemba molondola nthawi, zolemba zonse za mankhwala, komanso chisamaliro cha chilolezo chodziwitsidwa komanso chinsinsi, zolemba zachipatala zimakhala chida chothandiza komanso chotetezeka cholankhulirana ndi zachipatala. Pamapeto pake, zolemba zabwino sizimangoteteza akatswiri azaumoyo komanso zimawonetsetsa kuti odwala amalandira chisamaliro chokhazikika, choyenera, komanso chapamwamba.
Ngati mukufuna, nditha kupanganso template ya SOAP yokonzeka kugwiritsidwa ntchito (ya odwala osapita kuchipatala, chipinda chadzidzidzi, kapena odwala omwe ali m'chipatala) malinga ndi zosowa zanu.
