从谈话到文本:将医生患者沟通研究的弧度扩展到实时访问文档
1Medicine and Geriatrics, Regenstrief Institute, Indiana University School of Medicine, United States.
Patient education and counseling
|February 13, 2026
概括
电子健康记录 (EHR) 的广泛采用在医生与患者之间的沟通中带来了挑战. 医疗期间的记录 (DWD) 可能会对患者的护理产生负面影响,需要进一步调查.
科学领域:
- 医学沟通 医学沟通
- 医疗信息学 医疗信息学
- 临床实践中的临床实践
背景情况:
- 医生与病人沟通的研究自从近90年前开始以来,已经有了显著的进化.
- 音频和视频记录在分析临床相互作用的细微差别方面发挥了重要作用.
- 电子健康记录 (EHR) 整合到临床实践中已经成为几乎普遍的,到2023年,90%的美国医生办公室将使用它们.
研究的目的:
- 提供基于直接观察的医生与患者沟通研究的历史概述.
- 描述"高效临床医生的四个习惯"框架的发展.
- 检查电子健康记录 (EHR) 中记录的同时提供护理 (DWD) 对沟通和结果的影响.
主要方法:
- 关于医生与患者沟通的观察性研究的历史审查.
- "高效临床医生的四个习惯"框架的描述.
- 介绍POISED记忆器,以指导患者接触期间使用电子记忆器.
主要成果:
- 由于效率和计费压力,电子健康记录器迁移到考试室的数量有所增加.
- 关于DWD对医生与患者沟通和护理结果的影响,存在重大研究差距.
- 新出现的证据表明,DWD可能会导致临床医生的注意力分散,不准确的数据记录,以及潜在的较差的患者结果.
结论:
- 需要在不同的医学专业和患者群体进行进一步的大规模研究.
- 了解沟通,文档和技术的相互作用对于优化医生与患者关系至关重要.
- DWD的成本和好处需要全面的调查,以提供最佳实践的信息.
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