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电子病历对护士工作的影响。

The effect of the electronic medical record on nurses' work.

作者信息

Robles Jane

机构信息

North Memorial Health Care, Robbinsdale, Minnesota, USA.

出版信息

Creat Nurs. 2009;15(1):31-5. doi: 10.1891/1078-4535.15.1.31.

Abstract

The electronic medical record (EMR) is a workplace reality for most nurses. Its advantages include a single consolidated record for each person; capacity for data interfaces and alerts; improved interdisciplinary communication; and evidence-based decision support. EMRs can add to work complexity, by forcing better documentation of previously unrecorded data and/or because of poor design. Well-designed and well-implemented computerized provider order entry (CPOE) systems can streamline nurses' work. Generational differences in acceptance of and facility with EMRs can be addressed through open, healthy communication.

摘要

电子病历(EMR)对大多数护士来说已成为工作中的现实。其优点包括为每个人提供单一的综合记录;具备数据接口和警报功能;改善跨学科沟通;以及提供基于证据的决策支持。电子病历可能会增加工作复杂性,原因是需要强制对以前未记录的数据进行更好的记录,和/或设计不佳。设计良好且实施得当的计算机化医嘱录入(CPOE)系统可以简化护士的工作。通过开放、健康的沟通,可以解决不同代人在接受电子病历和使用电子病历的熟练程度方面的差异。

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