一般实践中的环境书记:一个多视角的前后纵向混合方法研究
R C A van Linschoten1, C M van Loon2, L Joanknecht3
1Department of General Practice, Erasmus MC, Rotterdam, The Netherlands. r.vanlinschoten@erasmusmc.nl.
NPJ digital medicine
|March 2, 2026
概括
环境书记显著减少了全科医生 (GPs) 的临床文档时间,减轻了工作量. 然而,潜在的缺点,如不准确的摘要,需要进一步研究,以确保护理质量.
科学领域:
- 医疗信息学 医疗信息学
- 主要护理医学 医疗保健
- 人与计算机的交互
背景情况:
- 一般医生的高工作量会对临床医生的幸福感和患者护理质量产生负面影响.
- 环境写字器是新兴技术,可以减轻文档负担,但证据有限,特别是关于患者的观点.
- 现有的研究往往忽视了环境书记对临床体验的多方面的影响.
研究的目的:
- 评估环境书记在减少全科医生的临床文档时间方面的有效性.
- 评估环境书记对总咨询时间,文档质量以及患者和GP经验的影响.
- 探索环境书记在现实世界初级保健环境中的可接受性和使用模式.
主要方法:
- 进行了一项前性,多中心,多视角,前后纵向混合方法研究.
- 12名全科医生和接受培训的全科医生没有先前的环境写字体验参与了.
- 收集的数据包括535次咨询的临床文档时间,咨询时间,文档质量,患者/医生经验,可接受性和使用量,比起基线和干预期.
主要成果:
- 每次咨询的临床文档时间减少了42.7秒 (p < 0.0001).
- 总咨询时间保持不变.
- 定性调查结果表明,医生工作量减少,一些患者的沟通改善,同时还对摘要准确性和敏感数据处理存在担忧.
结论:
- 环境写作在减少文档负担和支持初级保健中的沟通方面表现有前途.
- 需要进行进一步的研究,以解决意想不到的后果,例如摘要的不准确性和对敏感信息讨论和临床推理的潜在影响.
- 缓解这些缺点对于优化环境写字技术实施时的护理质量和可访问性至关重要.
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