Assuntos
Medula Óssea/efeitos dos fármacos , Imunossupressores/administração & dosagem , Leucopenia/induzido quimicamente , Erros de Medicação , Metotrexato/administração & dosagem , Esclerose Múltipla Recidivante-Remitente/complicações , Diagnóstico Diferencial , Feminino , Febre/etiologia , Hematúria/induzido quimicamente , Humanos , Imunossupressores/efeitos adversos , Sistemas Computadorizados de Registros Médicos , Metotrexato/efeitos adversos , Pessoa de Meia-Idade , Esclerose Múltipla Recidivante-Remitente/tratamento farmacológico , Trombocitopenia/induzido quimicamente , Cateterismo Urinário , Transtornos Urinários/etiologiaRESUMO
The transition to electronic medical records (EMRs) often includes the transition from paper to electronic documentation, a topic less well described in the literature than other aspects of EMR adoption. As part of a broader EMR project, we have participated in the transition to electronic notes on the Medicine service of a teaching hospital affiliated with the University of Washington. During a one year period beginning in February 2005 we adopted the use of semi-structured documentation templates permitting both encoded and narrative text components for admission, progress, and procedure notes, and for some discharge summaries. Currently over 1400 notes are entered each week. Fifty eight percent are entered by residents, 20% by attending physicians, and the remainder by other trainees and staff. The period of greatest change from paper to electronic notes occurred (by design) during the late spring and summer. Leadership, application functionality, speed, note writing time requirements, data availability, training needs, and other factors influenced adoption of this important part of our EMR.
Assuntos
Hospitais de Ensino/organização & administração , Sistemas Computadorizados de Registros Médicos , Interface Usuário-Computador , Humanos , Sistemas Computadorizados de Registros Médicos/estatística & dados numéricos , Corpo Clínico Hospitalar , Inovação Organizacional , WashingtonRESUMO
Titles of clinical notes within an electronic medical record (EMR) are important because they influence the speed and completeness of the review of a patient's health record. We created a note classification scheme for notes in our EMR consisting of a 2 level hierarchy of note titles used to identify newly created and existing text and scanned notes. In a sample of 3 of the 18 months since beginning production use, an average of 2,810 notes are added each day. The number of distinct note titles rose by 32 percent between November 2003 and February 2005. Few changes were made to the upper level of the hierarchy. Thirty-three note titles accounted for 75% of the notes entered in February 2005. Note titles are one of several attributes that in conjunction with the user interface used to display them may affect the efficiency and completeness with which clinicians review their patient's records.
