Jirjis Jim, Weiss Jacob B, Giuse Dario, Rosenbloom S Trent
Department of Internal Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA.
AMIA Annu Symp Proc. 2005;2005:375-9.
Interpersonal communications related to healthcare delivery, called clinical communications, take up a considerable amount of time. Nonetheless, there exist few tools in electronic health record systems that support clinical communications. We describe a framework for clinical communications and describe our experiences implementing tools to manage and document them within an electronic health record system. Categories of clinical communications include communications between patients and healthcare providers, among healthcare providers on a single clinical team, between healthcare providers in different clinical teams and different institutions, and between healthcare providers and individuals who can provide additional educational or evidence based materials to support care delivery.
与医疗服务提供相关的人际沟通，即临床沟通，会占用大量时间。然而，电子健康记录系统中支持临床沟通的工具却很少。我们描述了一个临床沟通框架，并介绍了我们在电子健康记录系统中实施管理和记录这些沟通的工具的经验。临床沟通的类别包括患者与医疗服务提供者之间的沟通、单个临床团队内医疗服务提供者之间的沟通、不同临床团队和不同机构的医疗服务提供者之间的沟通，以及医疗服务提供者与能够提供额外教育或循证材料以支持护理服务的个人之间的沟通。
