在电子病历环境中改善临床文档记录。
Improving clinical documentation in an EMR world.
作者信息
Payne Thomas
机构信息
IT services, UW Medicine, Seattle, USA.
出版信息
Healthc Financ Manage. 2010 Feb;64(2):70-4.
PMID:20178243
Abstract
Hospitals can take three steps to ensure successful integration of clinical documentation with an electronic medical record: Engage physicians and make sure they understand the process. Make the process simple for physicians to use. Train registered nurse documentation specialists to request documentation clarifications.
摘要
医院可以采取三个步骤来确保临床文档与电子病历成功整合
让医生参与进来并确保他们理解流程。使流程对医生来说易于使用。培训注册护士文档专家以要求澄清文档。
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