Simon Kelly Claire, Munson Richard, Ong Archie, Gil Fulvio R, Campanella Franco, Hillman Laura, Lai Rebekah, Chesis Richard, Tideman Samuel, Vazquez Rosa Maria, Meyers Steven, Frigerio Roberta, Maraganore Demetrius
Department of Neurology, NorthShore University HealthSystem, Evanston, Illinois.
Health Information Technology, NorthShore University HealthSystem, Evanston, Illinois.
J Stroke Cerebrovasc Dis. 2019 May;28(5):1229-1235. doi: 10.1016/j.jstrokecerebrovasdis.2019.01.011. Epub 2019 Feb 6.
Standardized electronic medical record tools provide an opportunity to efficiently provide care that conforms to Best Practices and supports quality improvement and practice-based research initiatives.
We describe the development of a customized structured clinical documentation "toolkit" that standardizes patient data collection to conform to Best Practices for treating patients with stroke. The toolkit collects patients' demographic information, relevant score test measures, and captures information on disability, treatment, and outcomes.
We describe here our creation and implementation of the toolkits and provide example screenshots. As of August 1, 2018, we have evaluated 2332 patients at an initial visit for a possible stroke. We provide basic descriptive data gathered from the use of the toolkits, demonstrating their utility in collecting patient data in a manner that supports both quality clinical care and research initiatives.
We have developed an EMR toolkit to support Best Practices in the care of patients with stroke. We discuss quality improvement projects and current research initiatives using the toolkit. This toolkit is being shared with other Departments of Neurology as part of the Neurology Practice-Based Research Network.
标准化电子病历工具为高效提供符合最佳实践的医疗服务提供了契机，并支持质量改进和基于实践的研究计划。
我们描述了一个定制化结构化临床文档“工具包”的开发过程，该工具包使患者数据收集标准化，以符合治疗中风患者的最佳实践。该工具包收集患者的人口统计学信息、相关评分测试指标，并获取有关残疾、治疗和结果的信息。
我们在此描述工具包的创建与实施，并提供示例截图。截至2018年8月1日，我们已对2332例初诊可能患有中风的患者进行了评估。我们提供了从工具包使用中收集的基本描述性数据，展示了其在以支持高质量临床护理和研究计划的方式收集患者数据方面的效用。
我们开发了一个电子病历工具包，以支持中风患者护理的最佳实践。我们讨论了使用该工具包的质量改进项目和当前研究计划。作为基于神经病学实践的研究网络的一部分，该工具包正在与其他神经病学部门共享。
