Tang P C, Fafchamps D, Shortliffe E H
Northwestern University School of Medicine, Chicago, IL.
Proc Annu Symp Comput Appl Med Care. 1994:575-9.
We conducted an observational study at a university hospital clinic to determine the success with which physicians find patient information using traditional hospital records as the source of data. We recorded 168 consecutive patient cases presented to attending physicians by internal medicine residents, and analyzed the transcripts to identify questions indicating that the physicians could not find patient information in the medical record. In 81 percent of the cases, physicians could not find all the patient information that they desired during a patient's visit. We performed thematic analysis to generate a set of 15 prototypical questions asked by physicians regarding patient information. The multiauthored medical record system we studied did not provide effective access to patient information for physicians making clinical decisions in an outpatient setting. Improved methods for addressing prototypical questions arising in routine practice are needed.
我们在一家大学医院诊所进行了一项观察性研究，以确定医生使用传统医院记录作为数据来源查找患者信息的成功率。我们记录了内科住院医师向主治医生汇报的168例连续患者病例，并分析了文字记录，以识别表明医生在病历中找不到患者信息的问题。在81%的病例中，医生在患者就诊期间无法找到他们想要的所有患者信息。我们进行了主题分析，以生成一组医生提出的关于患者信息的15个典型问题。我们研究的多作者病历系统未能为在门诊环境中做出临床决策的医生提供有效的患者信息获取途径。需要改进解决常规实践中出现的典型问题的方法。
