电子医疗记录连接问卷对有效护理文档的影响:可用性和有效性研究
Kana Kodama1, Shozo Konishi1, Shirou Manabe1,2
1Department of Medical Informatics, Osaka University Graduate School of Medicine, Suita, Japan.
JMIR nursing
|August 27, 2023
概括
一个新的患者自我报告系统通过将患者数据转换为电子医疗记录,显著减少了护理文档的时间. 这项技术提高了护理效率,并减轻了文档负担.
科学领域:
- 医疗保健信息学 医疗保健信息学
- 护理工作流程优化工作流程优化
- 患者参与技术的技术
背景情况:
- 护理文档构成了护士工作负载的很大一部分.
- 目前的护理记录依赖于患者报告,但不是字面转录.
- 关于将患者报告记录在电子医疗记录中的系统及其对记录时间的影响的研究有限.
研究的目的:
- 开发一个患者自我报告系统,准确地将患者数据转换为护理记录.
- 评估该系统在减少护士的文件负担方面的有效性.
主要方法:
- 采用了电子医疗记录集成问卷和入院前护理问卷.
- 患者的反应被引用到护理系统的患者简介中,用于住院患者的评估.
- 该研究比较了护士在使用电子问卷系统输入患者个人资料的时间与传统方法.
主要成果:
- 超过78%的患者使用电子问卷进行自我报告,报告使用方便 (88%) 和愿意重复使用 (85%).
- 使用电子问卷显著减少了护士输入患者个人资料的时间 (P<.001).
- 在内科病房和日常生活活动依赖的患者中观察到特定的时间缩短 (13% - 18%),而不会影响信息数量.
结论:
- 开发并实施了一种新的系统,在医院信息网络中捕获自我报告的患者数据,并将其集成到护理系统中.
- 实施的系统显然提高了护士任务记录的效率.
- 这些发现表明,患者自我报告系统是优化护理文档流程的可行策略.
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