Structured vs Unstructures Data Entry

医生每天收到的大量临床数据可能超过了人类处理信息的能力。计算机化的患者记录（CPR）采用由临床医生在护理点处输入的结构化数据，可以以有用的方式组织该信息。EpicCare（R）是Epic系统公司开发的心肺复苏术，将于2001年在费城儿童医院使用。儿科医生对结构化数据输入的态度，以及在儿科检查室的独特环境中记录输入的最佳机制是未知的。在这项试点研究中，医生的态度将通过调查来衡量，并将使用模板的结构化数据输入模式与使用语音的非结构化数据输入进行比较。结果将包括记录所花费的时间、记录的完整性和患者体验的质量。该试点的数据将用于设计后续的确定性研究，最终目标是完善护理点的数据输入机制。

The flood of clinical data a physician receives on a daily basis may exceed the human capacity to process information. A computerized patient record (CPR) employing structured data entry by clinicians at the point of care can organize this information in useful ways. EpicCare(R), the CPR developed by Epic Systems, Inc, will be deployed at the Children's Hospital of Philadelphia in 2001. The attitudes of pediatricians toward structured data entry, and the optimal mechanism of note entry in the unique environment of the pediatric exam room are unknown. In this pilot study physician attitudes will be measured by survey, and a structured data entry modality using templates will be compared to unstructured data entry using voice. Outcomes will include time spent on documentation, completeness of documentation, and quality of patient experience. Data from this pilot will be used to design a subsequent definitive study with the ultimate goal of refining the mechanisms of data entry at the point of care.