话语对急诊医学的影响 住院医生注意时间 完成 完成
Lauren R Willoughby1,2, Daniel J Hekman1,2, Benjamin H Schnapp2
1Medical College of Wisconsin, Department of Emergency Medicine, Milwaukee, Wisconsin.
The western journal of emergency medicine
|December 11, 2025
概括
语音大大提高了紧急医疗住院人员的笔记完成时间. 使用语音识别软件用于电子健康记录 (EHR) 文档导致更及时的患者护理和更好的连续性.
科学领域:
- 医疗信息学 医疗信息学
- 改善医疗保健质量 改善医疗保健质量
- 紧急医疗 紧急医疗
背景情况:
- 及时记录患者接触记录对于高质量的医疗保健和护理的连续性至关重要.
- 电子健康记录 (EHR) 越来越多地使用语音识别软件来提高文档效率.
- 话语对紧急医疗 (EM) 住院人员的文件及时性的影响需要调查.
研究的目的:
- 调查语录使用对紧急医疗 (EM) 住院医生的影响,在EHR中记录完成的时间.
- 为了比较在学术紧急情况部门的指挥和打字笔记之间的笔记完成的时间.
主要方法:
- 在一个为期三年的EM住院计划中,每学年从两个队列 (AY18-19和AY21-22) 中回顾分析了大约37,000张EHR笔记.
- 笔记的分析是基于语录的可用性,长度 (字符数) 和完成时间 (在24小时内或超过24小时).
主要成果:
- 在这两学年,使用语音与在24小时内完成笔记的更高率有关 (OR为AY18-19的1.3,OR为AY21-22的2.9).
- 综合数据显示,77.9%的笔记在24小时内完成,而70.9%的笔记在24小时内完成 (P < .001).
- 在这两个群体中,发音笔记平均比打字笔记长 (AY18-19:6,628比6,136个字符;AY21-22:6,531比6,347个字符;P<0.05).
结论:
- 在EM居民完成EHR笔记时使用语音大大增加了及时记录的可能性.
- 实施语录技术可以提高工作流程的效率,并可能提高患者护理的连续性.
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