在心理健康环境中护理文档时间的变化:对EHR使用数据的回顾性观察性研究
Jessica Kemp1,2, Hwayeon D Shin1,2, Charlotte Pape1
1Centre for Addiction and Mental Health, Toronto, Ontario, Canada.
Applied clinical informatics
|December 5, 2025
概括
护士面临着电子健康记录 (EHR) 造成的重大文档负担,这会影响患者的护理,并导致倦怠. 这项研究强调了场所和角色特定的EHR低效率,要求制定有针对性的优化策略.
科学领域:
- 医疗信息学 医疗信息学
- 护理信息学 护理信息学
- 医疗保健管理的管理
背景情况:
- 在加拿大,护士是电子健康记录 (EHR) 的首要用户.
- 护士所面临的文档负担和电子医疗记录效率低下是未被充分研究的.
- 现有的研究往往量化了EHR时间,但很少分析影响护理工作流程和患者护理的低效率.
研究的目的:
- 检查不同临床环境和角色的护士之间的EHR使用模式和时间分配.
- 确定特定的EHR组件,这些组件对护理工作量贡献最大.
- 确定预测电子健康记录所花费时间的因素,并评估临床场所使用模式的变化.
主要方法:
- 对一家大型学术精神卫生医院840名护士12个月使用电子病历数据的分析.
- 利用Cerner Advance (Oracle Health) 的数据,与护理咨询委员会合作选择了七个关键指标.
- 雇佣回归和最小平方意味着使用R进行比较,临床场所和护士类型作为预测变量.
主要成果:
- 在临床场所和护士类型之间观察到EHR使用的显著差异.
- 平均每位患者/班的EHR活动时间在住院 (19.3分钟) 中最高,紧随其后的是急诊 (14.8分钟) 和门诊 (6.3分钟) 设置.
- 注册实践护士 (RPNs) 比注册护士 (16.4分钟) 花费了更多的EHR活动时间 (20.1分钟),文档和PowerForms时间因场所和角色而异.
结论:
- 在护士-EHR互动中存在实质性的差异,文件化带来了显著的时间负担,特别是在RPN和住院环境中.
- 这些发现支持了针对特定临床环境和护理角色量身定制的有针对性的EHR优化策略的需求.
- 强调将护士的观点纳入EHR设计和质量改进计划的关键重要性,以提高效率和减少倦怠.
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