通过调整现有的医院软件来设计和实施电子病历
Tom Hebden1, Emyr Jones1, Robert Allcock2
1General Medicine, Great Western Hospitals NHS Foundation Trust, Swindon, GBR.
Cureus
|August 12, 2025
概括
一个新的电子患者记录 (EPR) 系统提高了临床文档的效率和及时的患者护理交付. 该系统消除了超过72小时的排放延迟,尽管最初的实施挑战.
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
- 医院工作流程优化工作流程优化
背景情况:
- 传统的纸质临床文档在效率和可访问性方面存在重大限制.
- 需要改进的电子系统来简化医院病房的笔记和患者信息管理.
研究的目的:
- 开发和评估一个定制的电子患者记录 (EPR) 系统,用于医院病房的临床笔记文档.
- 将新EPR系统的效率和对工作条件的影响与传统的基于纸张的方法进行比较.
主要方法:
- 采用了代的共同设计和与临床工作人员的积极参与.
- 在一项比较试验中,公司内部开发的EPR系统与纸张笔记进行了评估.
- 实施涉及跨多个医院病房的逐步方法,并进行不断的改进.
主要成果:
- EPR系统在医院出院时及时交付护理方面取得了显著的改进.
- 超过72小时的护理交付延迟被完全消除.
- 实施面临挑战,包括意识,培训,用户采用和IT硬件物流.
结论:
- 开发的EPR系统为改善临床文档和患者护理协调提供了可行的解决方案.
- 通过代性改进来解决实施挑战对于成功的广泛采用至关重要.
- 该研究强调了定制电子系统在医疗保健机构克服纸质记录局限性的潜力.
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