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从自由形式到框架:评估笔记模板对紧急医疗住院医疗决策文件的影响

Melissa Smith1, Anthony Han1, Ryan Ward1

  • 1Emergency Medicine, UT Southwestern Medical Center, Dallas, USA.

Cureus
|February 9, 2026
PubMed
概括

一个结构化医疗决策 (MDM) 笔记模板显著改善了急诊医学 (EM) 住院人员的文档质量. 该工具增强了关键的文档元素,支持更好的患者护理和计费实践.

关键词:
计费和编码方式临床文档 临床文档电子健康记录 电子健康记录紧急医疗 紧急医疗医疗决策中的医疗决策质量改善 质量改善居民教育 居民教育

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Methods of Documentation VII: EMR

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Flow Sheet

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Here's a closer look at the examples of flowsheets commonly used by nurses:
Graphic Sheet Documentation: