Appl Clin Inform - A qualitative analysis evaluating the purposes and practices of clinical documentation.

Tópicos

{ care(1570) inform(1187) nurs(1089) }
{ extract(1171) text(1153) clinic(932) }
{ process(1125) use(805) approach(778) }
{ data(3008) multipl(1320) sourc(1022) }
{ system(1050) medic(1026) inform(1018) }
{ design(1359) user(1324) use(1319) }
{ structur(1116) can(940) graph(676) }
{ result(1111) use(1088) new(759) }
{ algorithm(1844) comput(1787) effici(935) }
{ group(2977) signific(1463) compar(1072) }
{ use(1733) differ(960) four(931) }
{ survey(1388) particip(1329) question(1065) }
{ ehr(2073) health(1662) electron(1139) }
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{ research(1218) medic(880) student(794) }
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{ method(1219) similar(1157) match(930) }
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{ visual(1396) interact(850) tool(830) }
{ studi(1119) effect(1106) posit(819) }
{ activ(1138) subject(705) human(624) }
{ use(2086) technolog(871) perceiv(783) }
{ featur(3375) classif(2383) classifi(1994) }
{ take(945) account(800) differ(722) }
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{ data(1714) softwar(1251) tool(1186) }
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{ record(1888) medic(1808) patient(1693) }
{ model(2656) set(1616) predict(1553) }
{ first(2504) two(1366) second(1323) }
{ patient(1821) servic(1111) care(1106) }
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{ patient(2315) diseas(1263) diabet(1191) }
{ motion(1329) object(1292) video(1091) }
{ assess(1506) score(1403) qualiti(1306) }
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{ framework(1458) process(801) describ(734) }
{ error(1145) method(1030) estim(1020) }
{ chang(1828) time(1643) increas(1301) }
{ learn(2355) train(1041) set(1003) }
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{ method(1557) propos(1049) approach(1037) }
{ control(1307) perform(991) simul(935) }
{ model(2220) cell(1177) simul(1124) }
{ general(901) number(790) one(736) }
{ search(2224) databas(1162) retriev(909) }
{ featur(1941) imag(1645) propos(1176) }
{ case(1353) use(1143) diagnosi(1136) }
{ data(3963) clinic(1234) research(1004) }
{ risk(3053) factor(974) diseas(938) }
{ perform(999) metric(946) measur(919) }
{ research(1085) discuss(1038) issu(1018) }
{ import(1318) role(1303) understand(862) }
{ model(2341) predict(2261) use(1141) }
{ compound(1573) activ(1297) structur(1058) }
{ perform(1367) use(1326) method(1137) }
{ blood(1257) pressur(1144) flow(957) }
{ spatial(1525) area(1432) region(1030) }
{ health(3367) inform(1360) care(1135) }
{ model(3480) simul(1196) paramet(876) }
{ monitor(1329) mobil(1314) devic(1160) }
{ patient(2837) hospit(1953) medic(668) }
{ data(2317) use(1299) case(1017) }
{ age(1611) year(1155) adult(843) }
{ medic(1828) order(1363) alert(1069) }
{ signal(2180) analysi(812) frequenc(800) }
{ cost(1906) reduc(1198) effect(832) }
{ sampl(1606) size(1419) use(1276) }
{ gene(2352) biolog(1181) express(1162) }
{ intervent(3218) particip(2042) group(1664) }
{ time(1939) patient(1703) rate(768) }
{ can(981) present(881) function(850) }
{ analysi(2126) use(1163) compon(1037) }
{ cancer(2502) breast(956) screen(824) }
{ use(976) code(926) identifi(902) }
{ drug(1928) target(777) effect(648) }
{ implement(1333) system(1263) develop(1122) }
{ estim(2440) model(1874) function(577) }
{ activ(1452) weight(1219) physic(1104) }
{ method(1969) cluster(1462) data(1082) }
{ method(2212) result(1239) propos(1039) }
{ detect(2391) sensit(1101) algorithm(908) }

Resumo

JECTIVES: An important challenge for biomedical informatics researchers is determining the best approach for healthcare providers to use when generating clinical notes in settings where electronic health record (EHR) systems are used. The goal of this qualitative study was to explore healthcare providers' and administrators' perceptions about the purpose of clinical documentation and their own documentation practices.METHODS: We conducted seven focus groups with a total of 46 subjects composed of healthcare providers and administrators to collect knowledge, perceptions and beliefs about documentation from those who generate and review notes, respectively. Data were analyzed using inductive analysis to probe and classify impressions collected from focus group subjects.RESULTS: We observed that both healthcare providers and administrators believe that documentation serves five primary domains: clinical, administrative, legal, research, education. These purposes are tied closely to the nature of the clinical note as a document shared by multiple stakeholders, which can be a source of tension for all parties who must use the note. Most providers reported using a combination of methods to complete their notes in a timely fashion without compromising patient care. While all administrators reported relying on computer-based documentation tools to review notes, they expressed a desire for a more efficient method of extracting relevant data.CONCLUSIONS: Although clinical documentation has utility, and is valued highly by its users, the development and successful adoption of a clinical documentation tool largely depends on its ability to be smoothly integrated into the provider's busy workflow, while allowing the provider to generate a note that communicates effectively and efficiently with multiple stakeholders.

Resumo Limpo

jectiv import challeng biomed informat research determin best approach healthcar provid use generat clinic note set electron health record ehr system use goal qualit studi explor healthcar provid administr percept purpos clinic document document practicesmethod conduct seven focus group total subject compos healthcar provid administr collect knowledg percept belief document generat review note respect data analyz use induct analysi probe classifi impress collect focus group subjectsresult observ healthcar provid administr believ document serv five primari domain clinic administr legal research educ purpos tie close natur clinic note document share multipl stakehold can sourc tension parti must use note provid report use combin method complet note time fashion without compromis patient care administr report reli computerbas document tool review note express desir effici method extract relev dataconclus although clinic document util valu high user develop success adopt clinic document tool larg depend abil smooth integr provid busi workflow allow provid generat note communic effect effici multipl stakehold

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