单一的真相来源:在电子医疗记录中集中营养文档的案例
Jocelyn A Young1,2, Mary Beth Feuling3, Jeannie S Huang1,2
1Department of Pediatrics University of California, San Diego San Diego California USA.
JPGN reports
|February 16, 2026
概括
电子医疗记录 (EMR) 系统需要更好的营养文档. 在EMR中标准化营养信息对于患者安全和高效的医疗保健服务至关重要.
科学领域:
- 医疗保健信息学 医疗保健信息学
- 临床营养学 临床营养学
- 患者安全 患者安全
背景情况:
- 营养是患者护理的一个关键方面.
- 目前的电子医疗记录 (EMR) 系统缺乏集中营养信息.
- 这种缺陷影响医疗保健质量领域:安全,以患者为中心和效率.
研究的目的:
- 在EMR中确定改善营养评估,管理和安全的机会.
- 评估目前记录营养信息的做法.
- 探索挑战并收集改进建议.
主要方法:
- 一项12项在线调查被分发给儿科医疗保健提供者.
- 使用描述性统计和克鲁斯卡尔-瓦利斯测试分析了定量数据.
- 定性数据被主题分析.
主要成果:
- 从115名参与者中获得23%的响应率.
- 只有54%的人报告了食品过敏/不耐受性文档的标准化工作流程.
- 挑战包括缺乏标准位置,互操作性和营养计划不一致的数据.
- 73%的受访者知道与营养有关的安全事件.
结论:
- 迫切需要优化和标准化EMR中的营养文档.
- 医疗保健提供者主张统一的系统,以提高可见性和数据链接.
- 标准化对于加强患者安全和护理协调至关重要.
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