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通过医嘱录入系统实施住院临床记录采集的经验。

Experience in implementing inpatient clinical note capture via a provider order entry system.

作者信息

Rosenbloom S Trent, Grande Jonathan, Geissbuhler Antoine, Miller Randolph A

机构信息

Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA.

出版信息

J Am Med Inform Assoc. 2004 Jul-Aug;11(4):310-5. doi: 10.1197/jamia.M1461. Epub 2004 Apr 2.

Abstract

Care providers' adoption of computer-based health-related documentation ("note capture") tools has been limited, even though such tools have the potential to facilitate information gathering and to promote efficiency of clinical charting. The authors have developed and deployed a computerized note-capture tool that has been made available to end users through a care provider order entry (CPOE) system already in wide use at Vanderbilt. Overall note-capture tool usage between January 1, 1999, and December 31, 2001, increased substantially, both in the number of users and in their frequency of use. This case report is provided as an example of how an existing care provider order entry environment can facilitate clinical end-user adoption of a computer-assisted documentation tool-a concept that may seem counterintuitive to some.

摘要

尽管基于计算机的健康相关文档记录(“笔记捕捉”)工具具有促进信息收集和提高临床图表绘制效率的潜力,但医疗服务提供者对其采用率一直很低。作者开发并部署了一种计算机化的笔记捕捉工具,该工具已通过范德堡大学广泛使用的医疗服务提供者医嘱录入(CPOE)系统提供给终端用户。1999年1月1日至2001年12月31日期间,笔记捕捉工具的总体使用情况在用户数量及其使用频率方面都大幅增加。本案例报告旨在举例说明现有的医疗服务提供者医嘱录入环境如何促进临床终端用户采用计算机辅助文档记录工具——这一概念对某些人来说可能看似违反直觉。

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