Carle Foundation Hospital, USA.
University of Illinois College of Medicine at Urbana-Champaign, USA.
Health Inf Manag. 2023 May;52(2):87-91. doi: 10.1177/18333583211001584. Epub 2021 Apr 12.
Electronic medical record notes have been determined to be lacking in quality, accessibility and content. Structured note templates could provide a way to improve these aspects, particularly with regard to data availability for research and quality improvement.
To determine whether the implementation of a standardised template for hernia documentation can improve data completeness and timeliness.
Retrospective review of clinic notes of 30 patients, 15 prior to implementation of a standardised note template and 15 after implementation of the template. The number of the 21 Americas Hernia Society Quality Collaborative (AHSQC) variables which were present in the notes was recorded, as was the time that the consultation ended and the time that the note was submitted.
Mean number of variables collected prior to implementation of the template was 5.9 ± 1.6 vs. 20 ± 0.4 after implementation ( < 0.001). In the pre-implementation group, 20% of the notes were completed after the day of the visit, while all of the notes in the post-implementation group were completed on the same day as the visit ( = 0.367).
Implementation of a structured note template resulted in significantly improved capture of specific database variables within clinical notes. Structured note templates are an effective tool to improve data capture from the clinical setting for research and quality improvement.
电子病历记录的质量、可及性和内容一直存在不足。结构化的病历模板可以提供一种改进这些方面的方法，特别是在研究和质量改进方面的数据可用性方面。
确定实施疝病文档的标准化模板是否可以提高数据的完整性和及时性。
回顾性分析了 30 名患者的门诊记录，其中 15 名患者在实施标准化病历模板之前，15 名患者在实施模板之后。记录了病历中存在的 21 个美国疝病学会质量协作（AHSQC）变量的数量，以及咨询结束时间和提交病历的时间。
在实施模板之前，收集的变量的平均数量为 5.9 ± 1.6，而实施后为 20 ± 0.4（<0.001）。在实施前的组中，有 20%的病历是在就诊日之后完成的，而实施后的组中所有病历都是在就诊当天完成的（=0.367）。
实施结构化病历模板可显著提高临床病历中特定数据库变量的捕获率。结构化病历模板是一种有效的工具，可以提高从临床环境中获取数据的能力，从而进行研究和质量改进。
