Silvey Garry M, Lobach David F, Macri Jennifer M, Hunt Megan, Kacmaz Roje O, Lee Paul P
Division of Clinical Informatics, Department of Community and Family Medicine, Duke University Medical Center, Durham, NC, USA.
AMIA Annu Symp Proc. 2005;2005:1116.
Capturing the nuances of clinical observations in an electronic format has been a major challenge in implementing electronic health records. In a formative evaluation study using three different methodologies, we identified that the greatest obstacle to point-of-care data entry for eye care was supporting free text annotation of clinical observations. To overcome this obstacle, we developed an approach that captures an image of a free text entry and associates this image with related data elements in an encounter note. Through simulated patient studies, we observed that this approach successfully supported complex documentation at the point of care by clinicians.
以电子格式捕捉临床观察的细微差别一直是实施电子健康记录的一项重大挑战。在一项使用三种不同方法的形成性评估研究中，我们发现眼保健即时护理数据录入的最大障碍是支持对临床观察进行自由文本注释。为克服这一障碍，我们开发了一种方法，该方法捕获自由文本条目的图像，并将此图像与会诊记录中的相关数据元素相关联。通过模拟患者研究，我们观察到这种方法成功地支持了临床医生在即时护理时进行复杂的文档记录。
