Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
J Am Med Inform Assoc. 2011 Mar-Apr;18(2):181-6. doi: 10.1136/jamia.2010.007237. Epub 2011 Jan 12.
Clinical documentation is central to patient care. The success of electronic health record system adoption may depend on how well such systems support clinical documentation. A major goal of integrating clinical documentation into electronic heath record systems is to generate reusable data. As a result, there has been an emphasis on deploying computer-based documentation systems that prioritize direct structured documentation. Research has demonstrated that healthcare providers value different factors when writing clinical notes, such as narrative expressivity, amenability to the existing workflow, and usability. The authors explore the tension between expressivity and structured clinical documentation, review methods for obtaining reusable data from clinical notes, and recommend that healthcare providers be able to choose how to document patient care based on workflow and note content needs. When reusable data are needed from notes, providers can use structured documentation or rely on post-hoc text processing to produce structured data, as appropriate.
临床文档是患者护理的核心。电子健康记录系统采用的成功与否可能取决于这些系统在支持临床文档方面的表现。将临床文档集成到电子健康记录系统中的一个主要目标是生成可重复使用的数据。因此,人们一直强调部署基于计算机的文档系统,这些系统优先考虑直接结构化文档。研究表明,医疗保健提供者在撰写临床记录时会重视不同的因素,如表达的生动性、对现有工作流程的适应性和可用性。作者探讨了表达性和结构化临床文档之间的紧张关系,回顾了从临床记录中获取可重复使用数据的方法,并建议医疗保健提供者能够根据工作流程和记录内容的需求选择记录患者护理的方式。当需要从记录中获取可重复使用的数据时,提供者可以使用结构化文档或根据需要依赖事后的文本处理来生成结构化数据。
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