Haberman Shoshana, Feldman Joseph, Merhi Zaher O, Markenson Glenn, Cohen Wayne, Minkoff Howard
From the Department of Obstetrics & Gynecology, Maimonides Medical Center, Brooklyn, New York; Preventive Medicine and Community Health, SUNY Downstate, Brooklyn, New York; Department of Obstetrics & Gynecology, Baystate Medical Center, Springfield, Massachusetts; Department of Obstetrics & Gynecology, North Bronx Healthcare Network, Bronx, New York.
Obstet Gynecol. 2009 Aug;114(2 Pt 1):311-317. doi: 10.1097/AOG.0b013e3181af2cb0.
To investigate the efficacy of enhancing an existing prompt system in our obstetric electronic medical record in regard to documentation of estimated fetal weights and indications for labor induction.
Preintervention rates of documentation of indications for labor induction and estimated fetal weight were established at two hospital sites that used the same obstetric electronic medical record system. A compliance adherence mechanism with an enhanced prompting system was installed at the intervention hospital. Changes in the percentage of records with completed documentation were then calculated at the intervention and control hospitals. Additionally, the effects of the intervention on the pattern of documentation of indications for labor induction and on the accuracy of estimated fetal weight were tested.
In the intervention hospital, the documentation rate increased from 42% to 69.4% for indications for labor induction, and from 55.7% to 77% for estimated fetal weight (both P<.001) during the study period although the estimated fetal weight documentation rate did not reach the level seen at base in the control hospital (92.5%). In the control hospital, there were no significant changes in rates of estimated fetal weight during the study period, but there was a decrease in indications for labor induction documentation rates. The accuracy of estimated fetal weights did not change with the enhanced documentation compliance mechanism.
Increasing the frequency and modifying the methodology of prompts in an electronic medical record increased the documentation of both estimated fetal weight and indications for labor induction but did not lead to full compliance with documentation.
I.
探讨增强我院产科电子病历中现有提示系统对估计胎儿体重记录及引产指征记录的效果。
在使用相同产科电子病历系统的两家医院确定引产指征和估计胎儿体重的干预前记录率。在干预医院安装了带有增强提示系统的依从性机制。然后计算干预医院和对照医院中记录完整的记录百分比的变化。此外，还测试了干预对引产指征记录模式和估计胎儿体重准确性的影响。
在干预医院，研究期间引产指征的记录率从42%提高到69.4%，估计胎儿体重的记录率从55.7%提高到77%（均P<0.001），尽管估计胎儿体重记录率未达到对照医院基线时的水平（92.5%）。在对照医院，研究期间估计胎儿体重率无显著变化，但引产指征记录率有所下降。估计胎儿体重的准确性并未因增强的记录依从性机制而改变。
增加电子病历中提示的频率并修改提示方法可提高估计胎儿体重和引产指征的记录，但并未导致完全符合记录要求。
I级
