Helstrom Julia M, Langenau Erik E, Sandella Jeanne M, Mote Beth L
Physician Trainer for Clinical Skills Testing, NBOME, 101 W Elm St, Suite 150, Conshohocken, PA 19428-2004.
J Am Osteopath Assoc. 2014 Apr;114(4):274-82. doi: 10.7556/jaoa.2014.053.
Candidates taking the Comprehensive Osteopathic Medical Licensing Examination-USA Level 2-Performance Evaluation (COMLEX-USA Level 2-PE) are currently evaluated on their ability to document clinical findings using a handwritten postencounter note. However, keyboard data entry is increasingly used for medical documentation.
To determine the use and perception of keyboard data entry among osteopathic medical students and residents in educational and clinical settings.
A Web-based survey regarding frequency of and preference for keyboard data entry was distributed to 9801 osteopathic medical students, 17,268 osteopathic residents, and 34 clinical deans of colleges of osteopathic medicine (COMs). In addition, 31 COMs' clinical skills center directors were contacted to participate in a telephone survey about the use of keyboard data entry in their centers.
A total of 1711 students, 1198 residents, 14 clinical deans, and 17 clinical skills center directors responded to the surveys. The majority of students (872 [51%]) reported using electronic keyboard data entry at their COM's clinical skills center for postencounter notes. Among respondents, 379 students (23%), 77 residents (9%), and 1 clinical dean reported that electronic keyboard data entry is never or rarely used during clinical rotations. Most trainees (1592 students [93%], 864 residents [94%]) reported that they were either comfortable or very comfortable with typing. Given the option of recording methods for SOAP (subjective, objective, assessment, plan) note findings on the COMLEX-USA Level 2-PE, 7 clinical deans were unsure of their students' preferences, while the remaining favored keyboard data entry (5) over handwriting (2). The majority of student and resident respondents would choose keyboard data entry (1009 [60%] and 511 [55%], respectively).
Osteopathic medical students and residents are comfortable with typing; they are exposed to and would prefer using an electronic form of entry for medical documentation. These results support a conversion from written postencounter notes to keyboard data entry of notes on the COMLEX-USA Level 2-PE.
参加美国骨病医学综合执照考试二级——实践评估（COMLEX - USA二级 - PE）的考生目前是通过手写的诊后记录来评估其记录临床发现的能力。然而，键盘数据录入在医疗记录中使用得越来越频繁。
确定骨病医学学生和住院医师在教育和临床环境中对键盘数据录入的使用情况及看法。
一项关于键盘数据录入频率和偏好的网络调查被分发给9801名骨病医学学生、17268名骨病住院医师以及34名骨病医学院（COM）的临床院长。此外，31名COM临床技能中心主任被联系参与一项关于其中心键盘数据录入使用情况的电话调查。
共有1711名学生、1198名住院医师、14名临床院长和17名临床技能中心主任回复了调查。大多数学生（872名[51%]）报告在其COM的临床技能中心使用电子键盘数据录入来记录诊后记录。在受访者中，379名学生（23%）、77名住院医师（9%）和1名临床院长报告在临床轮转期间从未或很少使用电子键盘数据录入。大多数实习生（1592名学生[93%]，864名住院医师[94%]）报告他们对打字感到舒适或非常舒适。在COMLEX - USA二级 - PE考试中，若可选择记录主观、客观、评估、计划（SOAP）记录发现的方法，7名临床院长不确定其学生的偏好，而其余的则更倾向于键盘数据录入（5名）而非手写（2名）。大多数学生和住院医师受访者会选择键盘数据录入（分别为1009名[60%]和511名[55%]）。
骨病医学学生和住院医师对打字感到舒适；他们接触过并且更倾向于使用电子形式录入医疗记录。这些结果支持将COMLEX - USA二级 - PE考试中的诊后手写记录转换为键盘数据录入。
