Ehrler Frederic, Wu Danny T Y, Ducloux Pascal, Blondon Katherine
Division of Medical Information Sciences, University Hospitals of Geneva, Geneva, Switzerland.
Department of Biomedical Informatics and Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA.
JAMIA Open. 2021 Jul 31;4(3):ooab046. doi: 10.1093/jamiaopen/ooab046. eCollection 2021 Jul.
Documentation at the bedside is still often initiated on paper before being entered in electronic charts, even after implementing electronic health records (EHRs). This 2-step process is time-consuming, a potential source of error, and hinders the use of real-time information. We developed the "Bedside mobility" smartphone application to facilitate bedside documentation in the EHR.
This study aims to evaluate the impact of our app in 2 wards of a teaching hospital with a pre-post design.
The duration and location of all documentation activities were recorded using a time motion study.
Using the app significantly decreased the duration of EHR documentation per hour of observation by 4.10 min ( = 0.003), while the time spent interacting with patient increased by 1.45 min although not significantly. Also, in the intervention period, the average duration of uninterrupted documentation episodes increased by 0.27 min ( = 0.16) and the uninterrupted interaction with patient increased by 8.50 min ( = 0.027).
By reducing the fragmentation of documentation workflow, decreasing the overall EHR documentation time and allowing nurses to spend more time with their patients, app use led to potential higher quality of care and higher patient satisfaction and may help maintain a smoother workflow.
Our mobile app has the potential to positively impact bedside nurses' clinical workflow and documentation, as well as patient-provider communication and relationship.
即使在实施电子健康记录（EHR）之后，床边记录通常仍先在纸上进行，然后再录入电子病历。这种两步流程既耗时，又可能出错，还阻碍了实时信息的使用。我们开发了“床边移动性”智能手机应用程序，以方便在电子病历中进行床边记录。
本研究旨在采用前后设计评估我们的应用程序在一家教学医院的两个病房中的影响。
使用时间动作研究记录所有记录活动的持续时间和地点。
使用该应用程序后，每小时观察的电子病历记录持续时间显著减少4.10分钟（P = 0.003），而与患者互动的时间增加了1.45分钟，尽管不显著。此外，在干预期，不间断记录时段的平均持续时间增加了0.27分钟（P = 0.16），与患者的不间断互动增加了8.50分钟（P = 0.027）。
通过减少记录工作流程的碎片化，减少电子病历的总体记录时间，并使护士有更多时间陪伴患者，应用程序的使用可能带来更高的护理质量和更高的患者满意度，并有助于保持更顺畅的工作流程。
我们的移动应用程序有可能对床边护士的临床工作流程和记录以及患者与医护人员的沟通和关系产生积极影响。
