Hockstein Maxwell A, Pope Sara N, Donnawell Kayla, Chavez Summer A, Bhat Lipika
Emergency Medicine, Emory University, Atlanta, USA.
Emergency Medicine, UH Regional Hospitals, Richmond Heights, USA.
Cureus. 2019 Feb 7;11(2):e4027. doi: 10.7759/cureus.4027.
Given the near-universal implementation of electronic medical records (EMRs) in emergency departments (EDs), emergency medicine (EM) residents spend significant time interfacing with EMRs without any established national curriculum to learn best practices. While EMRs have the potential to increase physician efficiency and improve the quality of documentation, they have also been cited as a factor in physician burnout. Understanding the target audience of the EMR, knowing what and when to chart, and practicing time-saving strategies can streamline the process of charting. We review the literature on the current state of EMR documentation by residents and provide recommendations for best practices.
鉴于电子病历（EMR）在急诊科（ED）几乎已得到普遍应用，急诊医学（EM）住院医师花费大量时间与电子病历交互，却没有既定的全国性课程来学习最佳实践方法。虽然电子病历有提高医生效率和改善文档质量的潜力，但它们也被认为是导致医生职业倦怠的一个因素。了解电子病历的目标受众、知道记录什么和何时记录，以及采用节省时间的策略，可以简化记录过程。我们回顾了关于住院医师电子病历文档现状的文献，并提供最佳实践建议。
