急诊医学学员的电子健康记录记录时间

Scott Crawford, Igor Kushner, Radosveta Wells, Stormy Monks
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引用次数: 0

摘要

医生花费大量时间使用电子健康记录(EHRs)记录病人的就诊情况。《有意义使用指南》使电子病历系统得到广泛应用,但并没有证明它们能节省时间。这项研究比较了在两种不同的电子病历系统中完成一份急诊科记录所需的时间,这些系统分别记录了三种不同的标准化模拟病人遭遇的视频。完成记录所需的总时间,包括书写和订购初始病史、体检和诊断研究的时间,以及提供医疗决策和处置的时间,记录下来并在不同培训级别的受训者之间进行比较。记录时间的唯一显著差异是通过分类,二年级和三年级实习生在Cerner系统上的记录速度明显快于四年级和一年级实习生(F = 8.36, p < .001)。系统的培训水平和经验会影响文档编制时间。
本文章由计算机程序翻译,如有差异,请以英文原文为准。

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Electronic Health Record Documentation Times among Emergency Medicine Trainees.

Physicians spend a large portion of their time documenting patient encounters using electronic health records (EHRs). Meaningful Use guidelines have made EHR systems widespread, but they have not been shown to save time. This study compared the time required to complete an emergency department note in two different EHR systems for three separate video-recorded standardized simulated patient encounters. The total time needed to complete documentation, including the time to write and order the initial history, physical exam, and diagnostic studies, and the time to provide medical decision making and disposition, were recorded and compared by trainee across training levels. The only significant difference in documentation time was by classification, with second- and third-year trainees being significantly faster in documenting on the Cerner system than fourth-year medical student and first-year trainees (F = 8.36, p < .001). Level of training and experience with a system affected documentation time.

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来源期刊
CiteScore
1.90
自引率
0.00%
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期刊介绍: Perspectives in Health Information Management is a scholarly, peer-reviewed research journal whose mission is to advance health information management practice and to encourage interdisciplinary collaboration between HIM professionals and others in disciplines supporting the advancement of the management of health information. The primary focus is to promote the linkage of practice, education, and research and to provide contributions to the understanding or improvement of health information management processes and outcomes.
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