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医生在患者诊疗过程中使用计算机化病历系统:一项描述性研究。

Physician use of a computerized medical record system during the patient encounter: a descriptive study.

作者信息

Warshawsky S S, Pliskin J S, Urkin J, Cohen N, Sharon A, Binztok M, Margolis C Z

机构信息

Division of Health in the Community, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.

出版信息

Comput Methods Programs Biomed. 1994 Jun;43(3-4):269-73. doi: 10.1016/0169-2607(94)90079-5.

Abstract

The computerized medical record program, CLINIC, specifically designed at Ben-Gurion University of the Negev to be used on-line in a primary care clinic during a patient encounter by healthcare professionals, has been in use for over 6 years in two community clinics. In order to analyse the effectiveness and use of CLINIC, four physicians were video recorded during working sessions before and after the introduction of CLINIC. While using CLINIC did not change the total mean encounter time, the lengths of the encounter components and record use did change. The physicians' work style changed from a 'conversational pattern' (continuous data recording) to a 'blocked pattern' (data entry at intervals).

摘要

计算机化病历程序CLINIC是由内盖夫本-古里安大学专门设计的,供医疗专业人员在基层医疗诊所的患者诊疗过程中在线使用。该程序已在两家社区诊所使用了6年多。为了分析CLINIC的有效性和使用情况,在引入CLINIC之前和之后,对四名医生在工作时段进行了录像。使用CLINIC虽然没有改变诊疗总平均时长,但诊疗各部分的时长和记录使用情况确实发生了变化。医生的工作方式从“对话模式”(持续记录数据)转变为“分段模式”(间隔输入数据)。

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