Communication through the electronic health record: frequency and implications of free text orders.
Communication through the electronic health record: frequency and implications of free text orders.
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通过电子健康记录进行通信：自由文本订单的频率和影响。
DOI：
10.1093/jamiaopen/ooaa020
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发表时间：
2020
期刊：
影响因子：
2.1
通讯作者：
Marquard,Jenna
中科院分区：
文献类型：
--
作者：
Kandaswamy,Swaminathan;Hettinger,AaronZ;Hoffman,DanielJ;Ratwani,RajM;Marquard,Jenna
非药物医嘱通信（CNMO）是医嘱提供者用于有关患者护理的异步通信的一种自由文本通信。本研究的目的是了解在何种程度上非药物订单被用于药物相关的通信。我们分析了26 524 CNMO放置在6家医院的样本。共有42%的非药物订单包含药物信息。在不同医院、提供者设置和提供者类型之间，CNMO的使用存在很大差异。使用CNMO传达药物相关信息可能导致延迟或错过药物治疗，接受本应停用的药物治疗，或根据不准确的信息做出重要的临床决策。未来的研究应该量化这些数据输入模式对实际用药错误率和由此产生的安全性问题的影响。
Communication for non-medication order (CNMO) is a type of free text communication order providers use for asynchronous communication about patient care. The objective of this study was to understand the extent to which non-medication orders are being used for medication-related communication. We analyzed a sample of 26 524 CNMOs placed in 6 hospitals. A total of 42% of non-medication orders contained medication information. There was large variation in the usage of CNMOs across hospitals, provider settings, and provider types. The use of CNMOs for communicating medication-related information may result in delayed or missed medications, receiving medications that should have been discontinued, or important clinical decision being made based on inaccurate information. Future studies should quantify the implications of these data entry patterns on actual medication error rates and resultant safety issues.