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巴西重症监护病房中电子病历系统使用情况的评估。

Evaluation of the use of electronic medical record systems in Brazilian intensive care units.

作者信息

Colleti Junior José, Andrade Alice Barone de, Carvalho Werther Brunow de

机构信息

Hospital Santa Catarina - São Paulo (SP), Brasil.

Instituto da Criança, Hospital das Clínicas, Universidade de São Paulo - São Paulo (SP), Brasil.

出版信息

Rev Bras Ter Intensiva. 2018 Jul-Sept;30(3):338-346. doi: 10.5935/0103-507X.20180057.

Abstract

OBJECTIVE

To examine the prevalence of the use of electronic medical record systems in Brazilian intensive care units and the perceptions of intensive care physicians regarding the contribution of electronic medical record systems toward improving safety and quality in clinical practice.

METHODS

Using an online questionnaire, physicians working in Brazilian intensive care units answered questions about the use of electronic medical record systems in the hospitals in which they worked. They were asked about the types of electronic medical record systems used and their levels of satisfaction with these systems in terms of improving quality and safety.

RESULTS

Of the 4,772 invitations sent, 204 physicians responded to the questionnaire. Most used electronic medical record and prescription systems (92.6%), worked in private hospitals (43.1%), worked in general adult intensive care units (66.7%) and used Private System A (39.2%); most systems had been used for between 2 and 4 years (25.5%). Furthermore, the majority (84.6%) believed that the electronic system provided better quality than a paper system, and 76.7% believed that electronic systems provided greater safety than paper systems.

CONCLUSION

Electronic medical record systems seem to be widely used by the Brazilian intensive care physicians who responded to the questionnaire and, according to the data, seem to provide greater quality and safety than do paper records.

摘要

目的

调查巴西重症监护病房电子病历系统的使用情况,以及重症监护医师对电子病历系统在提高临床实践安全性和质量方面所做贡献的看法。

方法

通过在线问卷,在巴西重症监护病房工作的医师回答了有关他们所在医院电子病历系统使用情况的问题。询问了他们使用的电子病历系统类型以及他们对这些系统在提高质量和安全性方面的满意度。

结果

在发出的4772份邀请中,有204名医师回复了问卷。大多数人使用电子病历和处方系统(92.6%),在私立医院工作(43.1%),在普通成人重症监护病房工作(66.7%),使用私有系统A(39.2%);大多数系统使用了2至4年(25.5%)。此外,大多数人(84.6%)认为电子系统比纸质系统质量更好,76.7%的人认为电子系统比纸质系统更安全。

结论

回复问卷的巴西重症监护医师似乎广泛使用电子病历系统,并且根据数据,电子病历系统似乎比纸质记录提供更高的质量和安全性。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/11f0/6180478/6c3decf8ae1a/rbti-30-03-0338-g01.jpg

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