用技术重写笔记:临床文档的演变和未来
Romil Chadha1, Thaddeus R Salmon1, Leigh Anne Goodman2
1University of Kentucky College of Medicine, Lexington, KY, USA.
The Medical clinics of North America
|February 1, 2026
概括
临床文档复杂,受到法规和技术的影响,导致提供者倦怠. 需要人工智能和EHR重新设计等创新解决方案,以实现高效,有意义的文档和临床医生的福祉.
科学领域:
- 医疗信息学 医疗信息学
- 医疗文件 医疗文件
- 医疗保健管理部门的管理.
背景情况:
- 由于监管,财务和技术压力,临床文档已经显著发展.
- 目前的做法是由利益相关者塑造的,包括医疗保险和医疗补助服务中心 (CMS) 和保险公司.
- 文档对临床工作流程产生重大影响,并有助于减轻提供者的负担.
研究的目的:
- 追踪临床文档的历史演变.
- 分析现代临床文档的复杂性和挑战.
- 审查创新的解决方案,以提高文档效率,减少提供商的倦怠.
主要方法:
- 临床文档实践的历史分析.
- 审查当前的挑战,如笔记膨胀,低效率和倦怠.
- 探索创新解决方案,包括人工智能增强的工具和EHR设计修改.
主要成果:
- 文档实践受到外部利益相关者和系统的强烈影响.
- 显著的挑战包括笔记膨胀,工作流程效率低下和临床医生倦怠.
- 新兴的解决方案包括人工智能和重新设计的电子健康记录 (EHR).
结论:
- 利益相关者的合作和基于证据的改革至关重要.
- 目标是创建有意义和高效的文档.
- 改进文档支持临床医生的福祉,并提高了医疗保健的提供.
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