在患者电子医疗记录 (EMR) 中复制粘贴:谨慎使用并谨慎使用
Bassim Al Bahrani1,2, Itrat Medhi1
1Medical Oncology, The Royal Hospital, Muscat, OMN.
Cureus
|July 18, 2023
概括
电子医疗记录 (EMR) 简化了护理,但复制粘贴功能可能会导致医疗错误. 仔细使用EMR复制粘贴对于准确的患者数据和改善医疗保健结果至关重要.
科学领域:
- 医疗信息学 医疗信息学
- 医疗文件 医疗文件
背景情况:
- 电子医疗记录 (EMR) 提供全面,安全的数字患者数据,用于明智决策和简化护理.
- 电子医疗记录增强了合作,减少了文书工作,提高了效率,当与基于证据的实践相结合时,可以带来更好的患者结果.
研究的目的:
- 分析电子医疗记录中"复制粘贴"功能的作用和影响.
- 评估临床文档中复制粘贴的好处和风险.
主要方法:
- 分析EMR系统特征,特别是"复制粘贴"功能.
- 对医生工作流依赖复制粘贴的审查 (高达35.7%).
- 评估临床医生报告的错误和与复制粘贴相关的患者不良事件 (25%的临床医生).
主要成果:
- 在EMR中复制粘贴可以节省医生的时间,并有助于及时捕获数据.
- 显著比例的临床医生 (25%) 报告复制粘贴有助于医疗错误.
- 风险包括数据的不准确性,过时信息的传播,不一致的笔记和掩盖的关键数据.
结论:
- 虽然复制粘贴在EMR中提供了效率,但其使用需要谨慎,以保持数据完整性和患者安全.
- 实施适当的教育和保障措施对于减轻与EMR复制粘贴相关的风险至关重要.
- 对于使用此功能的医疗保健专业人员来说,了解法律影响,包括潜在的医疗失误,至关重要.
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