电子健康记录和医生工作流程调整的策略和工具:范围审查协议
Oluwakemi Olufunmilayo Oluwole1, Nicole Haggarty2, Uche Ikenyei1
1Health Information Science Department,, Faculty of Information and Media Studies, University of Western Ontario, Faculty of Information and Media Studies (FIMS) BuildingHuron Drive, London, CA.
JMIR research protocols
|March 31, 2025
概括
本范围审查综合了将电子健康记录 (EHR) 与医生工作流程协调的策略. 它旨在提供一个工具包,以提高电子病历的可用性,减少医生倦怠,并提高患者护理.
科学领域:
- 医疗信息学 医疗信息学
- 临床工作流的优化 临床工作流优化
- 医生福利 医生福利
背景情况:
- 电子健康记录 (EHR) 有好处,但往往与医生的工作流程不一致,影响护理和福祉.
- 尽管有努力,但在与临床实践协调电子健康记录方面仍然存在重大差距.
- 对调整策略的全面理解对于有效实施至关重要.
研究的目的:
- 识别和综合医疗保健组织用于电子健康记录与医生工作流程协调的策略和工具.
- 为组织和研究人员提供一个实用的工具包.
- 突出知识差距,为未来的EHR-工作流集成研究提供帮助.
主要方法:
- 根据乔安娜·布里格斯研究所框架和PRISMA-ScR检查清单进行范围审查.
- 在多个数据库中进行了搜索 (MEDLINE,PubMed,Cochrane,CINAHL,Scopus,Embase,Web of Science).
- 专注于涉及医生在所有护理环境中直接照顾患者的研究;两位独立审稿人选了文献.
主要成果:
- 预计将有一个全面的策略,工具和干预措施工具包,以实现电子健康记录与医生工作流程的协调.
- 综合将为医疗保健组织提供实际指导.
- 结果将成为确定研究缺口和未来方向的基础.
结论:
- 审查将提供有关实施的EHR-医生工作流协调策略的见解.
- 它旨在评估当前方法的有效性和局限性.
- 最终的目标是提高EHR的可用性,减少医生倦怠,并提高患者护理.
相关概念视频
01:11Purpose of Health Records I
The vital purpose of health records is to provide a complete and accurate account of a patient's medical history, including communication, diagnostic and therapeutic orders, care planning, research, and quality review.
Here's a breakdown of how health records serve these purposes:
Here's a breakdown of how health records serve these purposes:
01:26Methods of Documentation II: POMR
The Problem-Oriented Medical Record (POMR) revolutionized medical record-keeping by introducing a systematic approach focusing on the patient's problems rather than merely listing symptoms. Dr. Lawrence Weed's introduction of this method in the 1960s marked a significant advancement in medical documentation. The POMR framework consists of four key components: the database, problem list, plan of care, and progress notes.
01:15Methods of Documentation VI: Case Management Model
The case management model is a multidisciplinary approach that involves healthcare professionals from diverse disciplines, such as physicians, nurses, therapists, social workers, and pharmacists, working collaboratively to address the various needs of patients. Each healthcare professional brings unique expertise and perspectives, contributing to a more comprehensive understanding of the patient's condition and tailoring treatment plans accordingly.
For example, a patient with a chronic illness...
For example, a patient with a chronic illness...
01:30Methods of Documentation VII: EMR
Electronic Medical Records (EMRs) primarily center around electronically documenting patients' health information within a single healthcare organization or practice. They contain essential clinical data related to a patient's medical history, diagnoses, medications, treatment plans, lab results, and other pertinent information relevant to the specific encounter or episode of care. EMRs are designed to streamline documentation and workflow processes within individual healthcare settings,...
01:18Guidelines and Strategies for Safe Computer Charting
The guidelines and strategies provided by the American Nurses Association (ANA) and the Canadian Nurses Association (CNA) offer essential principles for ensuring safe and secure computer charting systems in healthcare settings. Let's break down each recommendation:
Maintain Confidentiality and Security:
Maintain Confidentiality and Security:
01:30Health Information Technology and Healthcare Information System
Health Information Technology (HIT)
Health Information Technology, commonly called HIT, integrates advanced information systems and technology in healthcare settings. Its primary functions include:
Health Information Technology, commonly called HIT, integrates advanced information systems and technology in healthcare settings. Its primary functions include: