J Am Med Inform Assoc - Clinical documentation: composition or synthesis?

Tópicos

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Resumo

JECTIVE: To understand the nature of emerging electronic documentation practices, disconnects between documentation workflows and computing systems designed to support them, and ways to improve the design of electronic documentation systems.MATERIALS AND METHODS: Time-and-motion study of resident physicians' note-writing practices using a commercial electronic health record system that includes an electronic documentation module. The study was conducted in the general medicine unit of a large academic hospital.RESULTS: During the study, 96 note-writing sessions by 11 resident physicians, resulting in close to 100 h of observations were seen. Seven of the 10 most common transitions between activities during note composition were between documenting, and gathering and reviewing patient data, and updating the plan of care.DISCUSSION: The high frequency of transitions seen in the study suggested that clinical documentation is fundamentally a synthesis activity, in which clinicians review available patient data and summarize their impressions and judgments. At the same time, most electronic health record systems are optimized to support documentation as uninterrupted composition. This mismatch leads to fragmentation in clinical work, and results in inefficiencies and workarounds. In contrast, we propose that documentation can be best supported with tools that facilitate data exploration and search for relevant information, selective reading and annotation, and composition of a note as a temporal structure.CONCLUSIONS: Time-and-motion study of clinicians' electronic documentation practices revealed a high level of fragmentation of documentation activities and frequent task transitions. Treating documentation as synthesis rather than composition suggests new possibilities for supporting it more effectively with electronic systems.

Resumo Limpo

jectiv understand natur emerg electron document practic disconnect document workflow comput system design support way improv design electron document systemsmateri method timeandmot studi resid physician notewrit practic use commerci electron health record system includ electron document modul studi conduct general medicin unit larg academ hospitalresult studi notewrit session resid physician result close h observ seen seven common transit activ note composit document gather review patient data updat plan carediscuss high frequenc transit seen studi suggest clinic document fundament synthesi activ clinician review avail patient data summar impress judgment time electron health record system optim support document uninterrupt composit mismatch lead fragment clinic work result ineffici workaround contrast propos document can best support tool facilit data explor search relev inform select read annot composit note tempor structureconclus timeandmot studi clinician electron document practic reveal high level fragment document activ frequent task transit treat document synthesi rather composit suggest new possibl support effect electron system

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