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Recorded vignettes: a novel method for investigating documentation in the Electronic Healthcare Record (EHR)

机译:录制的小插曲:一种调查电子医疗记录(EHR)文件的新方法

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摘要

Background: 360 million consultations documented annually in England1 Accurate descriptors required for secondary data functions: Computerised decision support; Financial reimbursement; Audit; Disease prevalence monitoring and research Coding is not explicitly taught within the GP curriculum How do you research how clinicians document? Previous studies: use real patients2/actors3 interacting with clinician studied; Lack standardisation; Expensive. Why Allergy? Growing clinical problem; 2014 NICE guidelines4: Poor clinical documentation is a major issue in allergy; EHR can’t distinguish between intolerance and allergy; Incorrect labelling of patients; Adverse impact on patient care? Little known about coding practices in non-incentivised condition such as allergy. Method: A novel method developed to standardize research of EHR use. Filmed 6 short vignettes (21-50 secs) Monologue of common allergic presentations as if in consultation with a doctor. Digital photographs were included to replicate rashes. Electronic distribution of study files Documented vignettes in their own EHR Returned screen-prints to the researcher for analysis - Codes, free text and EHR functions Questionnaire - Exploring decision-making and validation of method Initially piloted on 1 GP and 2 trainees leading to refinements. Results 7 GPs and 15 GP trainees were recruited All successfully completed Data was returned from 4 different EHRs SystmOne (6), EmisLV (2), EmisWeb (6) and Vision (8) Screen prints effectively captured data with minor technical difficulties reported by 2 participants The study took 1 - 2 hours to complete: longer than expected from the pilot study.
机译:背景:每年在英格兰记录的3.6亿次诊治1辅助数据功能所需的准确描述符:计算机化决策支持;财务报销;审计;疾病患病率监测和研究GP课程未明确教授编码。您如何研究临床医生的文件资料?先前的研究:使用真正的患者2 /演员3与所研究的临床医生互动;缺乏标准化;昂贵。为什么过敏?日益严重的临床问题; 2014年NICE指南4:不良的临床文档是过敏的主要问题; EHR无法区分不宽容和过敏;患者标签不正确;对患者护理产生不利影响?对于在未受刺激的情况下(例如过敏)的编码实践鲜为人知。方法:开发了一种新的方法来标准化EHR使用的研究。拍摄了6个短片(21-50秒),就像是在看医生的情况下一样,对常见的过敏反应进行了独白。包括数码照片以复制皮疹。电子分发研究档案,以自己的EHR形式记录渐晕记录,将屏幕打印返回给研究人员进行分析-代码,自由文本和EHR功能问卷调查-探索方法的决策和验证最初在1名GP和2名受训者身上进行了试验,以进行完善。结果招募了7名GP和15名GP学员所有成功完成的数据是从4个不同的EHR中返回的。SystmOne(6),EmisLV(2),EmisWeb(6)和Vision(8)返回的丝网印刷有效地捕获了由2报告的技术难度较小的数据参与者本研究需要1-2个小时才能完成:比初步研究预期的时间更长。

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    Glew Simon; Smith Helen;

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  • 年度 2015
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  • 正文语种 {"code":"en","name":"English","id":9}
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