医院处方软件中的强制性指示与抗菌药物处方一起测试
Lorna Pairman1, Paul Chin1,2, Sharon J Gardiner2,3,4
1Department of Medicine, University of Otago, Christchurch, New Zealand.
概括
电子处方指示字段的强制性显著改善了药物原因的文档. 这种增强导致记录的指示大幅增加,最少的非相关文本条目.
科学领域:
- 医疗信息学 医疗信息学
- 临床药房 临床药房
- 医疗文件 医疗文件
背景情况:
- 电子处方系统对于药物安全至关重要.
- 准确的指示文档对于临床决策和审计至关重要.
- 电子处方系统当前的自由文本字段往往缺乏结构化数据.
研究的目的:
- 评估电子处方系统中强制性指示字段对自由文本文档的影响.
- 评估处方者的行为对药物指示条目的变化.
- 开发一种可视化工具,用于监测指示提供.
主要方法:
- 七种抗菌药物的指示字段是强制性的.
- 在干预前和后4周内分析了处方数据.
- 指示字段中的自由文本被手动分类为"表示存在"",其他文本"",垃圾文本"或"空白".
- 开发了一个交互式报告,以可视化指示数据.
主要成果:
- 在干预后,指示供应从10.6%显著增加到72.4% (p<0.01).
- "其他文本"条目从7.6%增加到25.1% (p<0.01).
- "废文本"条目显示,从0.0%增加到0.6% (p<0.01).
结论:
- 实施强制性指示字段可以大大改善药物指示的文档.
- 干预导致有用的指示数据大幅增加,对文本质量产生最小的不利影响.
- 交互式报告工具可以支持电子处方的持续审计和质量改进举措.
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