急诊科的电子病历：急诊科临床医生复苏记录实践与认知的横断面调查

Electronic Medical Record in the ED: A Cross-Sectional Survey of Resuscitation Documentation Practices and Perceptions Among Emergency Department Clinicians.

作者信息

Franco Marleny, Baird Janette, Brown Linda L, Overly Frank L

出版信息

Pediatr Emerg Care. 2018 May;34(5):303-309. doi: 10.1097/PEC.0000000000001441.

DOI:10.1097/PEC.0000000000001441

PMID:29596279

Abstract

OBJECTIVES

The aims of this study were to describe current practices in nursing documentation of trauma and medical resuscitations across emergency departments (EDs) and explore physicians' and nurses' perceptions of electronic medical record (EMR) use for nursing documentation of resuscitations.

METHODS

An anonymous Web-based survey was developed and distributed to a convenience sample of ED physicians and nurses in the United States.

RESULTS

Of 438 respondents, 154 were nurses; 97.2% of respondents reported that their EDs use EMR generally. Of those, 51.2% use EMR to document resuscitations. When describing documentation processes, 19% (95% confidence interval [CI], 15%-23%) reported direct documentation on EMR, 18% (95% CI, 14%-21%) reported documenting on paper before transferring to EMR, and 22% (95% CI, 18%-26%) reported simultaneously documenting on EMR and paper. Thirty-seven percent of respondents reported that the "documentor" frequently performs other tasks during resuscitations. Few nurses (39.6%) and physicians (26.4%) perceived EMR as more efficient than paper. Nurses (66.2%) and physicians (51.8%) perceived paper as more complete than EMR. Few nurses (31.6%) and physicians (25.6%) agreed that paper would facilitate continuity of care better than EMR. No associations between nurses' perceptions of EMR, professional experience, or technology use were found.

CONCLUSIONS

Although EMR adoption was common among respondents, only half reported using EMR to document resuscitations. Even fewer reported documenting directly on EMR, whereas a significant proportion reported processes that may be inefficient, redundant, or prone to errors. Respondents endorsed mostly negative perceptions of EMR. Our findings suggest that there may be factors inherent to resuscitations and the existing EMR interfaces that render documenting resuscitations on EMR uniquely challenging.

摘要

目的

本研究旨在描述急诊科护理创伤和医疗复苏记录的当前做法，并探讨医生和护士对使用电子病历（EMR）进行复苏护理记录的看法。

方法

开展了一项基于网络的匿名调查，并分发给美国急诊科医生和护士的便利样本。

结果

在438名受访者中，154名是护士；97.2%的受访者报告称其所在的急诊科普遍使用电子病历。其中，51.2%使用电子病历记录复苏情况。在描述记录过程时，19%（95%置信区间[CI]，15%-23%）报告直接在电子病历上记录，18%（95%CI，14%-21%）报告先在纸上记录然后再转入电子病历，22%（95%CI，18%-26%）报告同时在电子病历和纸上记录。37%的受访者报告称“记录者”在复苏过程中经常执行其他任务。很少有护士（39.6%）和医生（26.4%）认为电子病历比纸质记录更高效。护士（66.2%）和医生（51.8%）认为纸质记录比电子病历更完整。很少有护士（31.6%）和医生（25.6%）同意纸质记录比电子病历更有助于护理的连续性。未发现护士对电子病历的看法、专业经验或技术使用之间存在关联。

结论

尽管电子病历在受访者中普遍采用，但只有一半的人报告使用电子病历记录复苏情况。甚至更少的人报告直接在电子病历上记录，而相当一部分人报告的流程可能效率低下、多余或容易出错。受访者对电子病历大多持负面看法。我们的研究结果表明，复苏本身以及现有的电子病历界面可能存在一些固有因素，使得在电子病历上记录复苏情况具有独特的挑战性。