Clinical Documentation Improvement for Outpatients by Implementing Electronic Medical Records

被引：4
|
作者：
Seto, Ryoma [1 ]
Inoue, Toshitaka [2 ,3 ]
Tsumura, Hiroshi [1 ]
机构：
[1] Tokyo Healthcare Univ, Fac Healthcare, Div Healthcare Informat, Tokyo, Japan
[2] Nishikyushu Univ, Fac Hlth & Social Welf Sci, Dept Social Welf Sci, Saga, Japan
[3] Seishinkai Inoue Hosp, Fukuoka, Fukuoka, Japan
来源：
NURSING INFORMATICS 2014: EAST MEETS WEST ESMART+ | 2014年 / 201卷
基金：
日本学术振兴会;
关键词：
Electrical Medical Records (EMR); Clinical Documentation Improvement (CDI); Staff Workloads;
D O I：
10.3233/978-1-61499-415-2-102
中图分类号：
TP [自动化技术、计算机技术];
学科分类号：
0812 ;
摘要：
This observational study was conducted before and after implementing an electronic medical record (EMR) system to evaluate the change in outpatient workflow by implementation of EMR and the effectiveness of clinical documentation improvement (CDI). The number of hours for patient care increased by 89.2% (p<.05) and the hours for writing medical records after consulting decreased after implementation of EMR by27.3% (p<.01). Implementation of EMR reduced nurses' workload to handle medical records by 78.8 (p<.05) but not changed for physicians. The necessary change in the information management process occurred after using the CDI indicator. We recommend that the "working hours of health professionals" and "handling hours for information resources" should be used widely as CDI indicators to improve workflow when implementing EMR.
引用
收藏
页码：102 / 107
页数：6
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