Lilholt Lars, Haubro Camilla Dremstrup, Møller Jørn Munkhof, Aarøe Jens, Højen Anne Randorff, Gøeg Kirstine Rosenbeck
Koncern IT, North Denmark Region, Aalborg, Denmark.
Stud Health Technol Inform. 2013;192:1129.
It is well-established that to increase acceptance of electronic clinical documentation tools, such as electronic health record (EHR) systems, it is important to have a strong relationship between those who document the clinical encounters and those who reaps the benefit of digitalized and more structured documentation. [1] Therefore, templates for EHR systems benefit from being closely related to clinical practice with a strong focus on primarily solving clinical problems. Clinical use as a driver for structured documentation has been the focus of the acute-physical-examination template (APET) development in the North Denmark Region. The template was developed through a participatory design where precision and clarity of documentation was prioritized as well as fast registration. The resulting template has approximately 700 easy accessible input possibilities and will be evaluated in clinical practice in the first quarter of 2013.
众所周知，为了提高对电子临床文档工具（如电子健康记录（EHR）系统）的接受度，临床会诊记录者与从数字化和结构化程度更高的文档中受益的人员之间建立牢固的关系非常重要。[1] 因此，EHR系统模板受益于与临床实践密切相关，并且高度专注于主要解决临床问题。临床应用作为结构化文档的驱动因素一直是丹麦北部地区急性体格检查模板（APET）开发的重点。该模板是通过参与式设计开发的，其中文档的精确性和清晰度以及快速录入被列为优先事项。最终的模板有大约700个易于访问的输入选项，并将于2013年第一季度在临床实践中进行评估。
