电子健康记录中的信息扭曲:一个概念分析分析
Jianan Wang1, Yihong Xu1, Rongrong Zhang1
1Nursing Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China.
电子健康记录 (EHR) 中信息的扭曲可能会损害患者的安全和信任. 了解其原因和后果是改善医疗保健文档和降低风险的关键.
科学领域:
- 医疗信息学 医疗信息学
- 医疗文件 医疗文件
- 改善医疗保健质量 改善医疗保健质量
背景情况:
- 电子健康记录 (EHR) 中的信息扭曲在现代医疗保健中是一个重大挑战.
- 准确可靠的健康信息对于有效的患者护理和临床决策至关重要.
研究的目的:
- 为了概念化电子健康记录中的信息扭曲.
- 建立一个理论框架,以提高医疗保健文档实践.
主要方法:
- 使用沃克和阿凡特的策略进行了严格的概念分析.
- 在主要数据库 (PubMed,科学网,Embase,CINAHL,Scopus) 进行了全面的文献搜索,截至2024年12月.
- 分析中包括了37项研究,这些研究解决了电子健康文件中信息扭曲的问题.
主要成果:
- 确定了信息扭曲的三个定义属性:现实世界的健康真相,现实表现和不匹配关系.
- 前例被分为五组:与人有关的,设备,监管,工作环境和管理因素.
- 其后果包括对患者安全的威胁,运营绩效下降,信任受到侵蚀,研究完整性受到损害以及健康不平等.
结论:
- 这种概念分析加深了对EHR信息扭曲的理解,为经验验证提供了基础.
- 结果可以为开发测量工具和策略提供信息,以减轻临床环境中的电子健康记录信息扭曲.
- 提高概念清晰度有助于分析有缺陷的EHR文档及其对医疗保健的系统影响.
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