Wurster Lee Ann, Groner Jonathan I, Hoffman Jeffrey
Emergency Department, Nationwide Children’s Hospital, 700 Children’s Dr, Columbus, OH 43205, USA.
J Trauma Nurs. 2012 Apr-Jun;19(2):76-9. doi: 10.1097/JTN.0b013e31825629ab.
Although many hospitals across the country have implemented an electronic medical record (EMR) for inpatient care, very few have successfully implemented an EMR for trauma resuscitations. Although there is evidence that the EMR improves patient safety, increases access to all care providers, increases workflow efficiency, and minimizes time spent on documenting thereby improving nursing care, the fast paced, complex nature of trauma resuscitations makes it difficult to implement such a system for trauma documentation. With the support of multiple disciplines with a variety of clinical knowledge, this article describes the design process that has led us to successful development and implementation of an EMR for documentation of trauma resuscitations.
尽管全国许多医院都已为住院护理实施了电子病历（EMR），但很少有医院成功为创伤复苏实施电子病历。虽然有证据表明电子病历可提高患者安全性、增加所有护理人员的信息获取、提高工作流程效率并减少记录时间从而改善护理，但创伤复苏的快节奏、复杂性质使得难以实施这样一个用于创伤记录的系统。在具有各种临床知识的多学科支持下，本文描述了使我们成功开发并实施用于创伤复苏记录的电子病历的设计过程。
