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2
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本文引用的文献

1
The quality of health care delivered to adults in the United States.美国为成年人提供的医疗保健质量。
N Engl J Med. 2003 Jun 26;348(26):2635-45. doi: 10.1056/NEJMsa022615.
2
Installing and implementing a computer-based patient record system in sub-Saharan Africa: the Mosoriot Medical Record System.在撒哈拉以南非洲地区安装并实施基于计算机的患者记录系统:莫索里奥医疗记录系统
J Am Med Inform Assoc. 2003 Jul-Aug;10(4):295-303. doi: 10.1197/jamia.M1301. Epub 2003 Mar 28.
3
A cross-site qualitative study of physician order entry.一项关于医生医嘱录入的跨站点定性研究。
J Am Med Inform Assoc. 2003 Mar-Apr;10(2):188-200. doi: 10.1197/jamia.m770.
4
Usability evaluation of the progress note construction set.病程记录构建集的可用性评估
Proc AMIA Symp. 2001:76-80.
5
A diffusion of innovations model of physician order entry.医生医嘱录入的创新扩散模型。
Proc AMIA Symp. 2001:22-6.
6
Clictate: a computer-based documentation tool for guideline-based care.Clictate:一种用于基于指南的护理的计算机化文档工具。
J Med Syst. 2002 Feb;26(1):47-60. doi: 10.1023/a:1013042920905.
7
Derivation and evaluation of a document-naming nomenclature.文档命名术语的推导与评估。
J Am Med Inform Assoc. 2001 Jul-Aug;8(4):379-90. doi: 10.1136/jamia.2001.0080379.
8
Standard method for describing an electronic patient record template: application of XML to share domain knowledge.描述电子病历模板的标准方法:XML在共享领域知识中的应用
Methods Inf Med. 2000 Mar;39(1):50-5.
9
Can history and physical examination be used as markers of quality? An analysis of the initial visit note in musculoskeletal care.病史和体格检查能否用作质量指标?肌肉骨骼护理初诊记录分析。
Med Care. 2000 Apr;38(4):383-91. doi: 10.1097/00005650-200004000-00005.
10
Implementation of clinical guidelines via a computer charting system: effect on the care of febrile children less than three years of age.通过计算机图表系统实施临床指南:对三岁以下发热儿童护理的影响。
J Am Med Inform Assoc. 2000 Mar-Apr;7(2):186-95. doi: 10.1136/jamia.2000.0070186.

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.

DOI:10.1197/jamia.M1461
PMID:15064293
原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC436080/
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。