Saviñon Carla, Taylor Julie Smith, Canty-Mitchell Janie, Blood-Siegfried Jane
University of North Carolina Wilmington, Wilmington, North Carolina 28403, USA.
J Am Acad Nurse Pract. 2012 Aug;24(8):463-71. doi: 10.1111/j.1745-7599.2012.00735.x. Epub 2012 Apr 26.
The purpose of this project was to determine if customization of the electronic medical record (EMR) using evidence-based practice guidelines developed by the National Association of Pediatric Nurse Practitioners and the Expert Panel recommendations for the prevention, screening, and treatment of childhood and adolescent overweight and obesity would improve the rate of screening and diagnosis of obesity in children, 7 to 18 years of age.
A retrospective review of encounters before and after implementation of customized EMR was conducted in a community health center. Data collected were compared for documentation of body mass index (BMI), completion of growth charts, scoring of risk questionnaire, and diagnosis of overweight or obesity.
There was a clear increase in the frequency of recording BMI, completing BMI growth charts, and scoring questionnaires between written and electronic medical records. The number of children diagnosed with overweight or obesity increased with customized EMR but still remains well below the rates of obesity for this community.
Customizing EMR with clinical practice guidelines improved adherence to recommendations for screening and identification of childhood overweight and obesity. Increased recognition and diagnosis will lead to improved interventions and improve outcomes for childhood obesity.
本项目的目的是确定使用由国家儿科护士从业者协会制定的循证实践指南以及专家小组关于预防、筛查和治疗儿童及青少年超重与肥胖的建议对电子病历（EMR）进行定制，是否会提高7至18岁儿童肥胖症的筛查和诊断率。
在一个社区健康中心对定制电子病历实施前后的诊疗记录进行了回顾性分析。比较收集到的数据，以了解体重指数（BMI）记录、生长图表填写、风险问卷评分以及超重或肥胖诊断情况。
纸质病历与电子病历相比，记录BMI、填写BMI生长图表以及问卷评分的频率明显增加。诊断为超重或肥胖的儿童数量因定制电子病历而增加，但仍远低于该社区的肥胖率。
根据临床实践指南定制电子病历可提高对儿童超重和肥胖筛查及识别建议的依从性。提高认知和诊断水平将有助于改善儿童肥胖症的干预措施并提高治疗效果。
