牙科实践中的数字临床记录与纸质记录:一项比较研究
Antonio Scarano1, Francesco Inchingolo2, Gianna Dipalma2
1Department of Innovative Technology in Medicine and Dentistry, University of Chieti-Pescara, Chieti, Abruzzo, Italy, unich.it.
BioMed research international
|December 31, 2025
概括
与纸质记录相比,电子健康记录 (EHR) 能够更快,更准确地识别健康风险,从而提高牙科患者的安全性. 这提高了临床效率,减少了牙科治疗计划中的医疗错误.
科学领域:
- 牙科信息学 牙科信息学
- 医疗记录管理 医疗记录管理
- 患者安全 患者安全
背景情况:
- 对患者病史的有效分析对于有效的牙科治疗计划至关重要.
- 电子健康记录 (EHR) 有助于识别患者的风险因素,如过敏和物质敏感性,减少医疗错误.
- 将EHR整合到牙科实践中可以提高关键系统性疾病的识别能力.
研究的目的:
- 为了比较电子健康记录 (EHR) 接口与传统纸质医疗记录 (PMR) 的有效性,用于评估牙科患者的病史.
- 评估EHR对确定牙科治疗关键健康信息的准确性和效率的影响.
- 在使用EHR与PMR时,评估患者病史中的忽视率.
主要方法:
- 一项涉及200名患者记录的比较研究,随机分配到EHR或PMR组.
- 20名牙科学生审查了分配的记录,以确定计划的牙科手术.
- 关键指标包括记录/报告时间和每个组的信息忽视次数.
主要成果:
- 使用EHR的牙科学生比使用PMR的牙科学生更快,更准确地识别了关键的系统性疾病.
- 在使用EHR的学生中没有发现过度监督,而PMR用户的平均过度监督数量明显高 (9.3 ± 0.46,p ≤ 0.01).
- 电子病历使用导致审查时间缩短,并提高了识别基本患者健康数据的准确性.
结论:
- 电子健康记录通过改善关键系统性疾病的识别,显著提高了牙科机构的患者安全和临床效率.
- 由于与软件,培训和技术支持相关的成本,电子健康记录的广泛采用可能会受到阻碍.
- 在牙科中实施EHR为风险评估和治疗规划提供了实质性的好处,有助于更安全的患者结果.
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