[计算机化的医疗记录. 从失去的幻想到更新的希望]
1Service de Radiothérapie, CHU Liège, Belgique.
Revue medicale de Liege
|September 12, 2024
概括
计算机化患者数据系统需要改进. 护理人员必须分享对数据质量的责任,并发展数据文化,以利用各种数据来源增强患者健康结果.
科学领域:
- 医疗信息学 医疗信息学
- 医疗记录管理 医疗记录管理
- 在医疗保健中的数据科学.
背景情况:
- 记录和传输患者数据的原则已经确立,但当前的计算机化医疗记录无法满足实际需求.
- 护理人员和管理人员对现有医疗记录系统的缺陷负有共同责任.
- 与医疗记录相关的幻灭和倦怠是医疗保健机构中普遍存在的问题.
研究的目的:
- 为了强调当前计算机化医疗记录的不足.
- 强调护理人员在提高数据质量方面的共同责任.
- 倡导发展一个强大的数据文化,以获得更好的健康结果.
主要方法:
- 分析计算机化患者数据系统当前的局限性.
- 讨论医疗保健提供者在数据管理中的作用.
- 探索医疗保健中的"数据文化"概念.
主要成果:
- 目前的计算机化医疗记录不能充分满足患者护理的需求.
- 护理人员和机构之间存在着改善数据系统的集体责任.
- 了解数据维度和培养数据文化对于利用数据至关重要.
结论:
- 恢复医疗记录的实用性是可以通过共同努力实现的.
- 技术解决方案可以自动化和简化医疗保健专业人员的数据记录任务.
- 发展数据文化对于利用多样化的数据源来改善个人和人口健康至关重要.
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