Yan Chen, Rose Susannah, Rothberg Michael B, Mercer Mary Beth, Goodman Kenneth, Misra-Hebert Anita D
Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, 9500 Euclid Avenue/NA21, Cleveland, OH, 44195, USA.
Department of Bioethics, Center for Ethics Humanities and Spiritual Care, Cleveland Clinic, 9500 Euclid Avenue, JJ60, Cleveland, OH, 44195, USA.
J Gen Intern Med. 2016 Sep;31(9):990-5. doi: 10.1007/s11606-016-3719-x. Epub 2016 Apr 29.
Extending medical assistants and nursing roles to include in-visit documentation is a recent innovation in the age of electronic health records. Despite the use of these clinical scribes, little is known regarding interactions among and perspectives of the involved parties: physicians, clinical scribes, and patients.
The purpose of this project is to describe perspectives of physicians, clinical scribes, and patients regarding clinical scribes in primary care.
We used qualitative content analysis, using Interpretive Description of semi-structured audio-recorded in-person and telephone interviews.
Participants included 18 physicians and 17 clinical scribes from six healthcare systems, and 36 patients from one healthcare system.
Despite physician concerns regarding terminology within notes, physicians, clinical scribes, and patients perceived more detailed notes because of real-time documentation by scribes. Most patients were comfortable with the scribe's presence and perceived increased attention from their physicians. Clinical scribes also performed more active roles during a patient visit, leading to formation of positive scribe-patient relationships. The resulting shift in workflow, however, led to stress. Our theoretical model for successful physician-scribe teams emphasizes the importance of interpersonal aspects such as communication, mutual respect, and adaptability, as well as system level support such as training and staffing.
Both interpersonal fit between physician and scribe, and system level support including adequate training, transition time, and staffing support are necessary for successful use of clinical scribes. Future directions for research regarding clinical scribes include study of care continuity, scribe medical knowledge, and scribe burnout.
在电子健康记录时代，将医疗助理和护理角色扩展至包括就诊记录是一项近期的创新举措。尽管使用了这些临床记录员，但对于参与各方（医生、临床记录员和患者）之间的互动以及他们的观点却知之甚少。
本项目旨在描述医生、临床记录员和患者对初级保健中临床记录员的看法。
我们采用定性内容分析方法，对面对面和电话进行的半结构化录音访谈运用诠释性描述。
参与者包括来自六个医疗系统的18名医生和17名临床记录员，以及来自一个医疗系统的36名患者。
尽管医生对记录中的术语存在担忧，但由于记录员的实时记录，医生、临床记录员和患者都认为记录更加详细。大多数患者对记录员在场感到自在，并感觉到医生给予了更多关注。临床记录员在患者就诊期间也发挥了更积极的作用，从而形成了积极的记录员 - 患者关系。然而，由此导致的工作流程转变产生了压力。我们关于成功的医生 - 记录员团队的理论模型强调人际方面（如沟通、相互尊重和适应性）以及系统层面支持（如培训和人员配备）的重要性。
医生与记录员之间的人际契合以及包括充分培训、过渡时间和人员配备支持在内的系统层面支持对于临床记录员的成功使用都是必要的。关于临床记录员的未来研究方向包括护理连续性研究、记录员医学知识研究以及记录员职业倦怠研究。
