Advance Care Planning Documentation in Electronic Health Records: Current Challenges and Recommendations for Change
Advance Care Planning Documentation in Electronic Health Records: Current Challenges and Recommendations for Change
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DOI：
10.1089/jpm.2017.0451
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发表时间：
2018-01-23
影响因子：
2.8
通讯作者：
Block, Susan
中科院分区：
文献类型：
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作者：
Lamas, Daniela;Panariello, Natalie;Block, Susan
目的：制定一套临床相关建议，以改善电子健康记录（EHR）中的提前护理计划（ACP）记录状态。背景：预先护理计划（ACP）是支持目标一致性护理的关键过程。为了实现偏好，临床医生必须能够可靠地记录、查找和使用ACP文档。然而，没有标准来指导电子健康记录（EHR）中的ACP文档。方法：我们采访了21个关键的线人，了解ACP的电子健康记录系统的优点和缺点，并确定最佳实践。我们使用定性内容分析方法对这些访谈进行了分析，并随后提出了一套初步建议。这些建议在国家内容专家小组的第二轮投入中得到了审查和完善。结果如下：信息提供者确定了六个主题，涉及目前在文件编制和获取非加太信息方面的不足之处以及改进的机会。讨论内容：我们提供了一套简明的、临床相关的建议，并以专家意见为依据，以改善EHR中ACP文档的状态。
Objective: To develop a set of clinically relevant recommendations to improve the state of advance care planning (ACP) documentation in the electronic health record (EHR). Background: Advance care planning (ACP) is a key process that supports goal-concordant care. For preferences to be honored, clinicians must be able to reliably record, find, and use ACP documentation. However, there are no standards to guide ACP documentation in the electronic health record (EHR). Methods: We interviewed 21 key informants to understand the strengths and weaknesses of EHR documentation systems for ACP and identify best practices. We analyzed these interviews using a qualitative content analysis approach and subsequently developed a preliminary set of recommendations. These recommendations were vetted and refined in a second round of input from a national panel of content experts. Results: Informants identified six themes regarding current inadequacies in documentation and accessibility of ACP information and opportunities for improvement. Discussion: We offer a set of concise, clinically relevant recommendations, informed by expert opinion, to improve the state of ACP documentation in the EHR.