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在精神科评估中使用模板进行临床文档记录——对住院医师培训有益还是适得其反?

Use of templates for clinical documentation in psychiatric evaluations-beneficial or counterproductive for residents in training?

机构信息

Department of Psychiatry, Drexel University College of Medicine, Philadelphia, Pennsylvania 19102, USA.

出版信息

Int J Psychiatry Med. 2012;43(1):99-103. doi: 10.2190/PM.43.1.g.

Abstract

In psychiatry, as in other disciplines, electronic templates are replacing handwritten records to meet health care financing regulations and requirements of third-party payers. We address whether these checklists are helpful for residents, especially those beginning training, in learning the foundational skills of their discipline and in recording a comprehensive set of patient data. An informal survey of our residents suggests that residents find the templates useful, though they have advantages and disadvantages. We also review relevant literature from psychiatry and other fields on the use of electronic templates and pose questions about how we might gauge the usefulness of the templates in residents' training and in obtaining valid data for clinical decision-making.

摘要

在精神病学领域,与其他学科一样,电子模板正在取代手写记录,以满足医疗保健融资法规和第三方付款人的要求。我们探讨这些清单是否对住院医师,特别是那些刚开始培训的住院医师,有帮助,以帮助他们学习学科的基础技能,并记录一套全面的患者数据。对我们住院医师的一项非正式调查表明,住院医师认为这些模板很有用,尽管它们有优点也有缺点。我们还回顾了精神病学和其他领域关于使用电子模板的相关文献,并提出了一些问题,即我们如何衡量模板在住院医师培训中的有用性以及为临床决策获取有效数据的能力。

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