Appl Clin Inform - Rapid implementation of inpatient electronic physician documentation at an academic hospital.

Tópicos

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Resumo

Electronic physician documentation is an essential element of a complete electronic medical record (EMR). At Lucile Packard Children's Hospital, a teaching hospital affiliated with Stanford University, we implemented an inpatient electronic documentation system for physicians over a 12-month period. Using an EMR-based free-text editor coupled with automated import of system data elements, we were able to achieve voluntary, widespread adoption of the electronic documentation process. When given the choice between electronic versus dictated report creation, the vast majority of users preferred the electronic method. In addition to increasing the legibility and accessibility of clinical notes, we also decreased the volume of dictated notes and scanning of handwritten notes, which provides the opportunity for cost savings to the institution.

Resumo Limpo

electron physician document essenti element complet electron medic record emr lucil packard children hospit teach hospit affili stanford univers implement inpati electron document system physician month period use emrbas freetext editor coupl autom import system data element abl achiev voluntari widespread adopt electron document process given choic electron versus dictat report creation vast major user prefer electron method addit increas legibl access clinic note also decreas volum dictat note scan handwritten note provid opportun cost save institut

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