Biomedical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA.
National Eye Institute, National Institutes of Health, Bethesda, MD, USA.
Stud Health Technol Inform. 2022 Jun 6;290:892-896. doi: 10.3233/SHTI220208.
Physicians can reduce their documentation time by working with a scribe. However, what scribes document and how their actions affect existing documentation workflows is unclear. This study leverages electronic health record (EHR) audit logs to observe how scribes affected the documentation workflows of seven physicians and their staff across 13,000 outpatient ophthalmology visits. In addition to editing progress notes, scribes routinely edited exam findings and diagnoses. Scribes with clinical training also edited items such as vital signs that a scribe without clinical training did not. Every physician edited patient records later in the day when working with a scribe and those who deferred their editing the most had some of the largest reductions in EHR time. These results suggest that what scribes document, how physicians work with scribes, and scribe impact on documentation time are all highly variable, highlighting the need for evidence-based best practices.
医生可以通过与抄写员合作来减少文档记录时间。然而，抄写员记录的内容以及他们的行为如何影响现有的文档工作流程尚不清楚。本研究利用电子健康记录 (EHR) 审核日志来观察抄写员如何影响七名医生及其工作人员在 13,000 次门诊眼科就诊中的文档工作流程。除了编辑进度记录外，抄写员还经常编辑检查结果和诊断。接受过临床培训的抄写员还编辑了生命体征等项目，而没有接受过临床培训的抄写员则不会编辑这些项目。每位医生在与抄写员一起工作时都会在当天晚些时候编辑患者记录，而那些最推迟编辑的医生的 EHR 时间则减少得最多。这些结果表明，抄写员记录的内容、医生与抄写员的合作方式以及抄写员对文档记录时间的影响都是高度可变的，这凸显了制定基于证据的最佳实践的必要性。
