Related Experiment Videos
Data acquisition behaviors during inpatient results review: implications for problem-oriented data displays
1Division of Clinical Informatics, Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA.
AMIA ... Annual Symposium Proceedings. AMIA Symposium
|January 24, 2007
Summary
Problem-oriented electronic medical records may alter physician data review. Physicians use complex behaviors with current systems, and problem-oriented records need further study to retain these benefits.
Area of Science:
- Medical Informatics
- Clinical Decision Making
- Human-Computer Interaction
Background:
- Electronic medical records (EMRs) are transitioning from source-oriented to problem-oriented formats.
- This shift may impact clinical decision-making processes.
- Understanding physician interaction with current EMR displays is crucial.
Purpose of the Study:
- To investigate how physicians interact with traditional laboratory data displays.
- To identify potential consequences of reorganizing patient data in EMRs.
- To assess the impact on clinical decision-making.
Main Methods:
- Pilot study utilizing verbal protocols and video screen capture.
- Physician subjects reviewed unfamiliar inpatient cases.
- Analysis focused on navigation and data acquisition behaviors within laboratory displays.
Main Results:
- Physicians primarily accessed laboratory displays to confirm existing findings.
- Anomalous laboratory results related to other problems were reviewed spontaneously 22% of the time.
- Physicians exhibit learned, complex data acquisition behaviors with source-oriented displays.
Conclusions:
- Physicians develop efficient interaction strategies with source-oriented EMRs.
- Problem-oriented EMRs must be designed to support these learned behaviors.
- Further research is needed to optimize problem-oriented EMRs without losing user benefits.
Related Concept Videos
01:24Data Reporting and Recording
Reporting and recording are crucial in data documentation. The timely, thorough, and accurate documentation of facts is essential when recording patient data. Failure to record findings during an assessment or interpretation of a problem will result in loss of information and make the patient document unreliable. The reader is left with general impressions if the information is not specific. A recording is documenting data of the individual's health information in a traceable, secure, and...
01:05Data Collection III
The physical assessment examines the patient for objective data that defines the patient's condition, and aids in formulating the nursing care plan. The purpose of physical assessment is a health status appraisal, which includes identifying health problems, and establishing a database for nursing intervention.
The principles to begin the physical assessment include conducting a comprehensive or problem-related history in a quiet, well-lit room, emphasizing privacy and comfort for the patient.
The principles to begin the physical assessment include conducting a comprehensive or problem-related history in a quiet, well-lit room, emphasizing privacy and comfort for the patient.
01:21Methods of Documentation III: PIE
Problem-intervention-evaluation (PIE) is a systematic approach to documentation used in healthcare settings for clinical decision-making and patient care planning. It is a structured approach to organizing patient data based on problems, interventions, and evaluations. Here's a breakdown of its key features and considerations:
01:10Documentation of Nursing Diagnosis
The nurse documents nursing diagnoses and enters them into the patient record. The identified patient's nursing diagnosis is either written out with a plan of care or entered into the electronic health record.
In some settings, data-driven computerized decision support systems are in place, allowing for more accurate nursing diagnoses. The database within one of these systems includes diagnostic labels defining characteristics, activities, and indicators for nursing. A nurse enters assessment...
In some settings, data-driven computerized decision support systems are in place, allowing for more accurate nursing diagnoses. The database within one of these systems includes diagnostic labels defining characteristics, activities, and indicators for nursing. A nurse enters assessment...
01:11Purpose of Health Records I
The vital purpose of health records is to provide a complete and accurate account of a patient's medical history, including communication, diagnostic and therapeutic orders, care planning, research, and quality review.
Here's a breakdown of how health records serve these purposes:
Here's a breakdown of how health records serve these purposes:
01:26Methods of Documentation II: POMR
The Problem-Oriented Medical Record (POMR) revolutionized medical record-keeping by introducing a systematic approach focusing on the patient's problems rather than merely listing symptoms. Dr. Lawrence Weed's introduction of this method in the 1960s marked a significant advancement in medical documentation. The POMR framework consists of four key components: the database, problem list, plan of care, and progress notes.