在临床文档中探索提供者对复制粘贴和复制转发的看法和态度
Matthew Hudkins1, Jeffrey A Gold2,3, Sky Corby3
1Division of Pediatric Critical Care, School of Medicine, Oregon Health and Science University, Portland, Oregon, United States.
Applied clinical informatics
|August 6, 2025
概括
在电子健康记录 (EHR) 中大量使用复制粘贴 (CP) 和复制转发 (CF) 提高了感知效率,但增加了文档错误. 使用和感知因临床环境和提供者角色而异,需要定制解决方案.
科学领域:
- 医疗信息学 医疗信息学
- 医疗文件 医疗文件
- 电子健康记录 (EHR) 是一种电子健康记录.
背景情况:
- 复制粘贴 (CP) 和复制转发 (CF) 是EHR系统中普遍存在的工具,旨在提高提供者的效率.
- 然而,这些工具可能会增加文档负担,笔记膨胀和潜在错误,对提供者的看法理解有限.
- 提供者对CP和CF对文档质量和效率的影响的观点仍未得到充分研究.
研究的目的:
- 调查提供者对CP和CF的看法和自我报告的使用模式.
- 分析这些工具如何影响各种临床环境和提供者角色的临床文档质量和效率.
- 了解供应商对未来使用CP和CF的态度.
主要方法:
- 在一个大型学术医疗中心,对医学学生,实习生和教师进行了一项调查.
- 该调查收集了关于文档化实践,CP/CF的感知好处和风险以及未来使用态度的数据.
- 对来自913名受访者的数据进行了定量和定性分析.
主要成果:
- 报告了CP (82%) 和CF (52%) 的高利用率,根据临床环境有显著的变化 (例如,在住院初级服务中最高,在ED中最低).
- 大多数提供者 (86%) 认为CP/CF提高了效率,但大多数人承认这些工具加剧了文档错误.
- 提供者更喜欢复制自己的笔记 (90% CP,82% CF),而不是其他人的笔记 (61% CP,47% CF).
结论:
- 自我报告的CP和CF的使用量很高,这是由于感知到的效率提高,尽管人们意识到相关的文档错误和笔记膨胀.
- 在实践环境中,CP/CF的使用模式和感知不同,这表明需要细微的,特定于工作流程的解决方案.
- 未来的干预措施应该平衡文档质量和效率,考虑到具体的实践环境和提供者的作用.
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