为电子环境重新解释护理记录:发展原则
Nicholas R Hardiker1, Dawn Dowding2, Patricia C Dykes3,4
1School of Human & Health Sciences, University of Huddersfield, UK.
Studies in health technology and informatics
|July 25, 2024
概括
电子健康记录系统需要改善护理文档. 这项研究探讨了利益相关者需要开发更好的系统来支持护理实践和数据使用.
科学领域:
- 医疗信息学 医疗信息学
- 护理信息学 护理信息学
- 人与计算机的交互
背景情况:
- 电子健康记录 (EHR) 系统为护理转型提供了潜力,但它们对质量和安全的全面影响尚未实现.
- 电子健康记录系统的护理组件需要在结构,内容和利用方面进行重新概念化,以与临床实践保持一致.
- 当前的EHR文档方法可能无法最佳地支持护理工作流程或促进有效的数据使用.
研究的目的:
- 在EHR系统中探索护理文档中的问题和新方法.
- 让包括护士和EHR开发人员在内的各种利益相关者参与共同设计改进的文档解决方案.
- 制定适合护理实践的新EHR系统规范的原则.
主要方法:
- 在英国和美国进行了三个焦点小组.
- 使用半结构面试指南来促进讨论.
- 在数据分析中采用一种常见的反射方法.
主要成果:
- 结果被综合成与EHR护理文档相关的关键主题.
- 确定了在电子健康记录结构,内容和数据利用方面需要改进的具体领域.
- 制定了一套开发原则,以指导未来护理的EHR系统设计.
结论:
- 重新构思EHR护理文档对于实现这些系统的全部潜力至关重要.
- 参与护士和开发人员的合作开发对于创建有效的EHR解决方案至关重要.
- 由此产生的原则可以为设计新型电子病历系统提供信息,以更好地支持护理实践和数据管理.
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