会诊中所说内容与电子健康记录中所记录内容的差异。
Differences Between What Is Said During the Consultation and What Is Recorded in the Electronic Health Record.
作者信息
Lacroix-Hugues Virginie, Azincot-Belhassen Sarah, Staccini Pascal, Darmon David
机构信息
Université Côte d'Azur, Département d'enseignement et de recherche en médecine générale, Nice, France.
CHU de Nice, Département de Santé Publique, Nice, France.
出版信息
Stud Health Technol Inform. 2019 Aug 21;264:674-678. doi: 10.3233/SHTI190308.
UNLABELLED
Electronic Health Records (EHRs) can be used for research but this raises the problem of data quality.
OBJECTIVE
To evaluate the quality of the information recorded in an EHR by a general practitioner (GP) during a regular office consultation.
METHOD
191 dialogs between the GP and patient were recorded and translated into the International Classification of Primary Care Second edition (ICPC-2) codes. Written information of the corresponding EHR was extracted and coded for comparison.
RESULTS
The primary reason for the consultation was recorded in the EHR in 41.2% of the cases and the diagnosis in 44.1% of the cases. Diagnoses noted in the EHR were less often communicated to the patients than the primary reasons (p<0.0001).
CONCLUSION
There is a loss of information between the dialog during a consultation and what is reported in the EHR. Consequences in terms of continuity and safety of care can be expected.
未标注
电子健康记录（EHRs）可用于研究，但这引发了数据质量问题。
目的
评估全科医生（GP）在常规门诊咨询期间记录在电子健康记录中的信息质量。
方法
记录了191次全科医生与患者之间的对话，并将其转换为《国际初级保健分类第二版》（ICPC - 2）编码。提取并编码了相应电子健康记录的书面信息以供比较。
结果
41.2%的病例中咨询的主要原因记录在电子健康记录中，44.1%的病例中诊断记录在电子健康记录中。电子健康记录中记录的诊断与患者沟通的频率低于主要原因（p<0.0001）。
结论
咨询期间的对话与电子健康记录中报告的内容之间存在信息丢失。预计在护理的连续性和安全性方面会产生后果。
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