The Time Needed for Clinical Documentation versus Direct Patient Care - A Work-sampling Analysis of Physicians' Activities
The Time Needed for Clinical Documentation versus Direct Patient Care - A Work-sampling Analysis of Physicians' Activities
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DOI：
10.3414/me0569
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发表时间：
2009-01-01
影响因子：
1.7
通讯作者：
Spoetl, H.-P.
中科院分区：
文献类型：
--
作者：
Ammenwerth, E.;Spoetl, H.-P.
目标：医疗保健专业人员似乎面临着越来越多的高质量，及时，以病人为导向的文件的需求。然而，文件任务的稳步增加已被证明与时间压力增加和医生工作满意度低有关。我们的目的是检查医生花费在临床和行政文件的任务的时间。我们分析了临床和行政文件所需的时间，并将其与其他任务，如直接patient care.Methods：在2个月的时间内（2006年12月至2007年1月），训练有素的研究人员完成了40小时的2分钟的工作抽样分析，从8个参与内科病房的200张病床的医院在奥地利。一个37项的分类系统被应用到分类任务分为五类（直接病人护理，通信，临床文件，行政文件，其他）。结果：从5555个观察点，医生花了26.6%的日常工作时间的文件任务，27.5%的直接病人护理，36.2%的沟通任务，和9.7%的其他任务。通常被视为管理的文档只需要大约。16%的总documentation时间。结论：几乎一样多的时间被花在文件，因为是花在直接的病人护理。基于计算机的工具，在某些领域，文件助理可能有助于减少临床和行政文件的工作。
Objectives: Health care professionals seem to be confronted with an increasing need for high-quality, timely, patient-oriented documentation. However, a steady increase in documentation tasks has been shown to be associated with increased time pressure and low physician job satisfaction. Our objective was to examine the time physicians spend on clinical and administrative documentation tasks. We analyzed the time needed for clinical and administrative documentation, and compared it to other tasks, such as direct patient care.Methods: During a 2-month period (December 2006 to January 2007) a trained investigator completed 40 hours of 2-minute work-sampling analysis from eight participating physicians on two internal medicine wards of a 200-bed hospital in Austria. A 37-item classification system was applied to categorize tasks into five categories (direct patient care, communication, clinical documentation, administrative documentation, other).Results: From the 5555 observation points, physicians spent 26.6% of their daily working time for documentation tasks, 27.5% for direct patient care, 36.2% for communication tasks, and 9.7% for other tasks. The documentation that is typically seen as administrative takes only approx. 16% of the total documentation time.Conclusions: Nearly as much time is being spent for documentation as is spent on direct patient care. Computer-based tools and, in some areas, documentation assistants may help to reduce the clinical and administrative documentation efforts.