Characteristics and Challenges of Clinical Documentation in Self-Organized Fast-Paced Medical Work
Characteristics and Challenges of Clinical Documentation in Self-Organized Fast-Paced Medical Work
复制标题
自组织快节奏医疗工作中临床记录的特点和挑战
DOI：
10.1145/3555111
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发表时间：
2022
影响因子：
--
通讯作者：
Park, Sun Young
中科院分区：
文献类型：
--
作者：
Zhang, Zhan;Joy, Karen;Harris, Richard;Park, Sun Young
临床记录是一项耗时且具有挑战性的任务，特别是在时间紧迫的医疗环境中。即使有专门的抄写员，在时间限制下及时准确地记录文档也绝非易事。在这项工作中，我们提出了一种独特的快节奏医疗团队——紧急医疗服务（EMS）——它没有指定的文件角色，同时不断在外地工作，提供紧急病人护理。通过对13位EMS从业者的访谈，我们揭示了EMS文档实践的几个有趣和突出的特征以及他们面临的相关挑战：EMS从业者在自我组织和协作文档的同时，在身体和认知上都专注于高敏度患者，实时使用手持文档系统的能力有限，并且被严格的文档要求和法规所淹没。最后，我们利用我们的研究结果讨论了技术和非技术影响，以支持在动态医疗环境中及时和协作的文档，同时考虑到护理提供者在使用计算设备时的身体和认知限制。
Clinical documentation is a time-consuming and challenging task, especially in time-critical medical settings. Even with a dedicated scribe person, timely and accurate documentation under time constraints is never easy. In this work, we present a unique type of fast-paced medical team--emergency medical services (EMS)--which has no designated role for documentation while constantly working outside in the field to provide urgent patient care. Through interviews with 13 EMS practitioners, we reveal several interesting and prominent characteristics of EMS documentation practice as well as their associated challenges: EMS practitioners self-organize and collaborate on documentation while in the meantime being both physically and cognitively preoccupied with high-acuity patients, having limited capability to use handheld documentation systems in real-time, and being overwhelmed by strict documentation requirements and regulations. Lastly, we use our findings to discuss both technical and non-technical implications to support timely and collaborative documentation in dynamic medical contexts while accounting for care providers' physical and cognitive constraints in using computing devices.
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影响因子：
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