...
  • 主题
高级搜索  >
历史搜索 清空历史
首页> 外文期刊>Acute Medicine & Surgery >Better documentation in electronic medical records would lead to an increased use of lower extremity venous ultrasound in the inpatient setting: a retrospective study
【24h】

Better documentation in electronic medical records would lead to an increased use of lower extremity venous ultrasound in the inpatient setting: a retrospective study

机译：回顾性研究：更好的电子病历记录将导致住院患者下肢静脉超声的使用增加

获取原文
           
页面导航
  • 摘要
  • 著录项
  • 相似文献
  • 相关主题

摘要

Aim We hypothesized that the quality of the assessment of abnormal laboratory data in the emergency department (ED) could affect the hospital‐attending physicians’ decision‐making after a patient's hospitalization. To test this hypothesis, we investigated how patients with a positive D‐dimer result were reported by ED physicians in electronic medical records, and measured whether lower extremity venous ultrasonography examination was undertaken during hospitalization by the hospital‐attending physicians. Methods In an urban tertiary acute care general hospital in Japan, between January 2012 and December 2013, we included patients hospitalized after a positive D‐dimer measurement (≥1.0?μg/mL) that was taken in the emergency department. We retrospectively measured the quality of ED physician assessments. Then we examined whether that affected the decisions of attending physicians to order lower extremity venous ultrasonography examinations during hospitalization. The exposure variable was the quality of the ED physicians’ assessment of patients with positive D‐dimer results. The outcome was whether a lower extremity venous ultrasonography examination was ordered by the attending physician during hospitalization. Results When assessments were described by ED physicians for patients with positive D‐dimer results, the attending physicians frequently ordered lower extremity venous ultrasonography (odds ratio, 10.74; 95% confidence interval, 5.92–19.50), even if the assessments only contained “copied and pasted” laboratory data (odds ratio, 1.68; 95% confidence interval, 2.10–2.40). Conclusions Better documentation by ED physicians, regarding patients with positive D‐dimer results, strongly affected the decisions made by attending physicians to order lower extremity venous ultrasonography examination. Several cross‐sectional studies have reported on the quality of electronic medical records (EMRs) in the clinical setting, whereas a study has shown the ease with which copy and paste can be used in EMRs. However, none of these studies could answer how much copied‐and‐pasted documentation was transmitted between physicians by the EMRs, and none investigated the influence of the assessment quality by the EMRs in a cohort setting, even retrospectively. Better documentation by emergency department physicians, regarding patients with positive D‐dimer results, strongly affected the decisions made by attending physicians to order lower extremity venous ultrasonography examination.
机译：目的我们假设急诊科（ED）中异常实验室数据的评估质量可能会影响患者住院后医院主治医师的决策。为了验证这一假设，我们调查了ED医师在电子病历中如何报告D-二聚体阳性的患者，并测量了住院医师在住院期间是否进行了下肢静脉超声检查。方法2012年1月至2013年12月间，在日本城市三级急诊综合医院中，我们纳入了急诊科D-二聚体阳性（≥1.0？μg/ mL）后住院的患者。我们回顾性地评估了急诊医师评估的质量。然后，我们检查了这是否影响了住院期间主治医师下令下肢静脉超声检查的决定。暴露变量是ED医师对D-二聚体结果阳性患者的评估质量。结果是住院期间主治医生是否下令进行了下肢静脉超声检查。结果当ED医师描述D-二聚体结果阳性的评估时，即使评估仅包含“已复制并粘贴”实验室数据（赔率，1.68; 95％置信区间，2.10–2.40）。结论ED医师关于D-二聚体结果阳性的患者更好的文献记录，极大地影响了主治医师下令下肢静脉超声检查的决定。几项横断面研究报告了临床环境中电子病历（EMR）的质量，而一项研究表明，在EMR中使用复制和粘贴很容易。但是，这些研究都无法回答EMR在医生之间传递了多少复制粘贴的文档，也没有人研究过EMR在同类人群中的评估质量的影响，甚至是回顾性研究。急诊科医师关于D-二聚体阳性的患者的更好文献记录，极大地影响了主治医师下令下肢静脉超声检查的决定。

著录项

相似文献

  • 外文文献
  • 中文文献
  • 专利
获取原文

客服邮箱：kefu@zhangqiaokeyan.com

京公网安备：11010802029741号 ICP备案号：京ICP备15016152号-6 六维联合信息科技 (北京) 有限公司©版权所有

  • 客服微信

  • 服务号