在患者护理需求和准确数据采集之间做出选择:探索护士过度文档负担的经验
Jennifer Thate1, Rachel Y Lee2, Rosemary Mugoya3,4
1Department of Nursing, Siena College, Albany, New York, United States.
Applied clinical informatics
|October 1, 2025
概括
由于电子健康记录 (EHR) 的可用性问题,护士们面临过度的文档负担 (ExDocBurden). 解决这些问题对于减少ExDocBurden和提高数据准确性以确保安全的患者护理至关重要.
科学领域:
- 护理信息学 护理信息学
- 健康信息管理 管理健康信息
- 临床文档 临床文档
背景情况:
- 过度的文档负担 (ExDocBurden) 影响急症护理机构的护士.
- 电子健康记录 (EHR) 是这种负担的一个重要来源.
- 由于文档过载,护士提供安全,高质量的护理的能力可能会受到损害.
研究的目的:
- 探索护士在急性护理中的过度文档负担 (ExDocBurden) 的经验.
- 确定导致住院护士ExDoc负担的因素.
- 收集护士们关于减轻ExDocBurden负担的解决方案的观点.
主要方法:
- 与18名急症护理护士进行了半结构化采访.
- 采访成绩单使用常数比较方法进行分析.
- 数据被分类为可用性问题和减少的策略.
主要成果:
- 关键的可用性问题包括EHR逻辑中的不准确数据,繁的流程表,通过检查框捕获有限的有意义信息,以及在不充分的培训中不断更新系统.
- 确定的主题是不准确的数据,漫长的流程表,勾选框限制和系统更改.
- 减排策略被分为当前的方法和未来的创新.
结论:
- 解决电子文档可用性问题对于减少ExDocBurden至关重要.
- 建议尽量减少结构化数据输入和增强临床推理捕获.
- 建议利用数据捕获和解析技术进行二次使用,以提高人工智能工具的数据质量.
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