Lagrew David C, Stutman Harris R, Sicaeros Laurie
Women's and Children's Department, Saddleback Memorial Medical Center, Laguna Hills, CA, USA.
Am J Obstet Gynecol. 2008 Jun;198(6):690.e1-5; discussion 690.e5-6. doi: 10.1016/j.ajog.2008.03.022.
The purpose of this study was to review the utilization statistics for voluntary physician adoption of a comprehensive inpatient electronic record by community obstetrician-gynecologists.
A retrospective analysis of administrative data on the utilization of a modern electronic medical record system in a private hospital setting was performed. The physician statistics for order entry and physician documentation pre- and postimplementation were compared.
During the study period monthly hospital average was 268 discharges per month and 64.9 orders per discharge. Utilizing the prior stand alone order entry system, 38.7% of orders were directly entered by physicians, and, following implementation, this rose to 72.1% with phone/verbal orders reduced by 44.9%. Monthly transcription rates of history and physical, consultations, operative and discharge summary notes were reduced by 61.5%, 75.8%, 56.6%, and 88.2%, respectively, over the study time period.
A well designed electronic medical record can be utilized in the voluntary private inpatient setting with significant physician adoption.
本研究旨在回顾社区妇产科医生自愿采用综合住院电子病历的使用统计数据。
对一家私立医院环境中现代电子病历系统使用情况的管理数据进行回顾性分析。比较了实施前后医生医嘱录入和医生记录的统计数据。
在研究期间，医院月平均出院人数为每月268人，每次出院平均医嘱数为64.9条。使用之前独立的医嘱录入系统时，38.7%的医嘱由医生直接录入，实施后这一比例升至72.1%，电话/口头医嘱减少了44.9%。在研究期间，病史与体格检查、会诊、手术和出院小结的每月转录率分别降低了61.5%、75.8%、56.6%和88.2%。
精心设计的电子病历可在私立住院环境中得到自愿采用，医生的接受程度较高。
