How physicians document outpatient visit notes in an electronic health record
How physicians document outpatient visit notes in an electronic health record
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DOI：
10.1016/j.ijmedinf.2012.04.002
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发表时间：
2013-01-01
影响因子：
4.9
通讯作者：
Bates, David W.
中科院分区：
文献类型：
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作者：
Pollard, Stephanie E.;Neri, Pamela M.;Bates, David W.
背景：临床文档是电子健康记录（EHR）中的一个重要过程，需要临床医生花费大量时间。如何最好地优化文档方法，以提供有效的care.Objective：我们评估是否EHR访问笔记文档方法的影响，由医生或实践的特点，和协会的医生满意度与EHR笔记模块。测量：我们调查了初级保健医生（PCP）和专家，并使用EHR和提供者数据对2008年的访视记录进行多项logistic回归。我们测量医生的文档方法的使用和满意度与EHR笔记模块，并确定方法和医生和实践characteristics.Results之间的关系：1088医生，85%使用单一的方法来记录他们的访问的大部分。PCP主要使用模板（60%）进行记录，而专家的这一比例为34%，而专家的这一比例为38%。隶属于学术医疗中心（OR 1.96，CI（1.23，3.12）），基于医院（OR 1.57，95% CI（1.04，2.36））和使用EHR时间较长（OR 1.13，95% CI（1.03，1.25））的医生更有可能口述而不是使用模板。大多数医生的383调查响应者满意的EHR笔记模块，无论他们的首选documentation method.Conclusions：医生主要利用一个单一的访问记录的文件，并与他们的方法感到满意，但他们选择的方法各不相同。人口统计学特征与首选的记录方法相关。进一步的研究应该集中在为什么存在差异，以及所使用的不同方法导致的文档质量。(C)2012爱思唯尔爱尔兰有限公司保留所有权利。
Background: Clinical documentation, an essential process within electronic health records (EHRs), takes a significant amount of clinician time. How best to optimize documentation methods to deliver effective care remains unclear.Objective: We evaluated whether EHR visit note documentation method was influenced by physician or practice characteristics, and the association of physician satisfaction with an EHR notes module.Measurements: We surveyed primary care physicians (PCPs) and specialists, and used EHR and provider data to perform a multinomial logistic regression of visit notes from 2008. We measured physician documentation method use and satisfaction with an EHR notes module and determined the relationship between method and physician and practice characteristics.Results: Of 1088 physicians, 85% used a single method to document the majority of their visits. PCPs predominantly documented using templates (60%) compared to 34% of specialists, while 38% of specialists predominantly dictated. Physicians affiliated with academic medical centers (OR 1.96, CI (1.23, 3.12)), based at a hospital (OR 1.57, 95% CI (1.04, 2.36)) and using the EHR for longer (OR 1.13, 95% CI (1.03, 1.25)) were more likely to dictate than use templates. Most physicians of 383 survey responders were satisfied with the EHR notes module, regardless of their preferred documentation method.Conclusions: Physicians predominantly utilized a single method of visit note documentation and were satisfied with their approach, but the approaches they chose varied. Demographic characteristics were associated with preferred documentation method. Further research should focus on why variation exists, and the quality of the documentation resulting from different methods used. (C) 2012 Elsevier Ireland Ltd. All rights reserved.