J Am Med Inform Assoc - Use of electronic clinical documentation: time spent and team interactions.

Tópicos

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Resumo

JECTIVE: To measure the time spent authoring and viewing documentation and to study patterns of usage in healthcare practice.DESIGN: Audit logs for an electronic health record were used to calculate rates, and social network analysis was applied to ascertain usage patterns. Subjects comprised all care providers at an urban academic medical center who authored or viewed electronic documentation.MEASUREMENT: Rate and time of authoring and viewing clinical documentation, and associations among users were measured.RESULTS: Users spent 20-103 min per day authoring notes and 7-56 min per day viewing notes, with physicians spending less than 90 min per day total. About 16% of attendings' notes, 8% of residents' notes, and 38% of nurses' notes went unread by other users, and, overall, 16% of notes were never read by anyone. Viewing of notes dropped quickly with the age of the note, but notes were read at a low but measurable rate, even after 2 years. Most healthcare teams (77%) included a nurse, an attending, and a resident, and those three users' groups were the first to write notes during an admission. Limitations The limitations were restriction to a single academic medical center and use of log files without direct observation.CONCLUSIONS: Care providers spend a significant amount of time viewing and authoring notes. Many notes are never read, and rates of usage vary significantly by author and viewer. While the rate of viewing a note drops quickly with its age, even after 2 years inpatient notes are still viewed.

Resumo Limpo

jectiv measur time spent author view document studi pattern usag healthcar practicedesign audit log electron health record use calcul rate social network analysi appli ascertain usag pattern subject compris care provid urban academ medic center author view electron documentationmeasur rate time author view clinic document associ among user measuredresult user spent min per day author note min per day view note physician spend less min per day total attend note resid note nurs note went unread user overal note never read anyon view note drop quick age note note read low measur rate even year healthcar team includ nurs attend resid three user group first write note admiss limit limit restrict singl academ medic center use log file without direct observationconclus care provid spend signific amount time view author note mani note never read rate usag vari signific author viewer rate view note drop quick age even year inpati note still view

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