内科病房对电子病历界面中相关临床数据需求的分析

Clinical Data Needs Analysis of the New EMR Interface in Medical Wards

临床数据是医生诊疗过程中进行临床决策的重要依据,本文基于某三级甲等综合医院内科病房25份来自对不同临床角色、不同使用目的、不同临床经验的3类临床工作者的新电子病历临床数据需求问卷调查结果,针对50项内科临床指标在临床决策中的贡献程度、重要性进行评估,筛选出10项重要临床决策性指标(血压、24小时出入量、cTNI、BNP、SaO_2、PaCO_2、Cr、K、Na、Cl),展示了新电子病历临床数据对不同临床工作角色的医务人员在提高临床决策效率方面的具体帮助,并初步揭示了新电子病历未来对保障医疗安全、提升医疗品质的潜在价值。

Clinical data is fundamental for clinical decision-making. The study aimed to find out how the new EMR could improve clinical decision-making efficiency for health care practitioners in different roles. We designed standard questionnaire included 50 common indicators and investigated among chief, attendance and residents working in medical wards. They were required to tick 10 most important indicators among all items. At last, 25 questionnaires were enrolled in data analysis. The outcome suggested the top 10 important indicators were blood pressure, 24 h input and output amount, c TNI,BNP,Sa O2,Pa CO2,Cr,K,Na,and Cl. We could recognize the details in clinical decision-making process from the results which revealed the potential needs on new EMR interface for efficiency improvement.