Resident Notes in an Electronic Health Record
Resident Notes in an Electronic Health Record
复制标题
电子健康记录中的居民注释
DOI：
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发表时间：
2017
期刊：
影响因子：
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通讯作者：
C. Phillipi
中科院分区：
文献类型：
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作者：
Megan Aylor;Emily M. Campbell;Christiane Winter;C. Phillipi
电子健康记录（EHRs）的采用迫使医疗文件的过渡，但很少有人知道在EHR临床医生的文件。本研究比较了住院医师在引入标准化笔记模板前后所写的电子病历，并调查了住院医师对电子病历文件的看法。共确定了454份驻地进度说明和610份示范介绍后的说明。新模板实施后，笔记长度缩短了263个字符（P = 0.004），平均结束时间延迟了73分钟（P < 0.0001）。在100条笔记的亚分析中，新模板的评估和计划部分缩短了46个单词（P < 0.01）。在调查受访者中，89%的人喜欢新的笔记模板，78%的人表示新的模板有助于完成笔记。常驻焦点小组揭示了对电子病历对笔记写作的贡献的矛盾心理。笔记模板导致了更短的笔记。住院医师喜欢电子病历模板，但不确定电子病历是否支持整体的病历书写。
Adoption of electronic health records (EHRs) has forced a transition in medical documentation, yet little is known about clinician documentation in the EHR. This study compares electronic inpatient progress notes written by residents pre- and post introduction of standardized note templates and investigates resident perceptions of EHR documentation. A total of 454 resident progress notes pre– and 610 notes post–template introduction were identified. Note length was 263 characters shorter (P = .004) and mean end time was 73 minutes later (P < .0001) with new template implementation. In subanalysis of 100 notes, the assessment and plan section was 46 words shorter with the new template (P < .01). Among survey respondents, 89% liked the new note templates, 78% stated the new templates facilitated note completion. The resident focus group revealed ambivalence toward the EHR’s contribution to note writing. Note templates resulted in shorter notes. Residents appreciate electronic note templates but are unsure if the EHR supports note writing overall.