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解决笔记膨胀问题:为有效的临床文档提供解决方案
Nicholas Genes1, Joseph Sills2, Heather A Heaton3
1Department of Emergency Medicine Ronald O. Perelman, NYU Grossman School of Medicine, New York, New York, USA.
Journal of the American College of Emergency Physicians open
|February 27, 2025
概括
临床文档或"笔记膨胀"在紧急医疗中是一个日益严重的问题. 本研究讨论了改善医疗笔记清晰度和简洁性的策略,以便更好地做出决策.
科学领域:
- 医疗信息学 医疗信息学
- 改善临床文档 改善临床文档
背景情况:
- 美国的临床文档越来越长,越来越难以阅读,被称为"笔记膨胀".
- 这一问题在紧急医疗中尤其具有挑战性,因为诊断的不确定性很高,需要快速做出决定.
- 导致笔记膨胀的因素包括计费优化,不当行为风险减轻和电子健康记录 (EHR) 功能.
研究的目的:
- 讨论改善临床笔记清晰度和简洁性的最佳实践.
- 探索最近的E/M编码改革对文档实践的影响.
- 考虑新兴技术 (如生成性人工智能) 在解决笔记膨胀方面的作用.
主要方法:
- 对临床文档最佳实践的现有证据和专家意见的审查.
- 分析最近的评估和管理 (E/M) 编码改革的影响.
- 讨论技术进步及其对医疗文档的潜在影响.
主要成果:
- 纸币膨胀是由金融,法律和技术因素的交汇驱动的.
- 电子/机器编码改革旨在简化文档,但面临着不同的实施.
- 像人工智能这样的新技术为文档提供了潜在的解决方案和新的挑战.
结论:
- 提高笔记清晰度和简洁性需要一个多方面的方法.
- 临床领导,电子健康记录供应商和专业组织之间的合作是必不可少的.
- 持续适应新技术和编码准则是必要的,以打击笔记膨胀.
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