Kufalitsa zam'mbuyo, zowonongeka
Kulemba-kulumikiza ndi imodzi mwa ntchito zothandiza kwambiri zomwe zimagwiritsidwa ntchito kwa ogwiritsa ntchito njira iliyonse yopezera zamagetsi. Madokotala amagwiritsa ntchito mauthenga a zaumoyo (EHRs) kuti alembetse tsatanetsatane wa chithandizo chaumoyo. Zambirizi zikuphatikizapo zizindikiro zomwe wodwala akupereka, kuyesa thupi, zotsatira za mayesero, matenda, matenda komanso zochitika. Pomwe vuto la wodwalayo liri lobwerezabwereza kapena lachilendo, wogwira ntchitoyo akuyenera kulembetsa zosinthidwa pa vuto lomwelo mobwerezabwereza.
Pofuna kuonjezera bwino, wodwala angagwiritse ntchito zikhomo kuti azibweretsa magawo ena a zolembedwera kuchokera ku zolemba zina kupita kumbuyo.
Ngakhale kulipira-phala ndi chida chothandizira kwa madokotala, zomwe zingayambitse zolakwa zolakwika, zosochera ndi zoopsa m'EHR . Zomwe zadandauliranso za anamwino akugwiritsa ntchito zolemba ndi kusindikiza pamapepala, zomwe zimapangitsa kuti zidziwitso kapena zochitika zina zisachitike. Nkhaniyi idzayang'ana pazitsulo zamakono zosayenerera-kopatsa.
Mauthenga Abwino Okhudza Kusamalira Odwala
Vuto lalikulu ndilokuti chidziwitso chomwe poyamba chinali cholondola chimakhala chosayenerera ngati chosasinthidwa kuti chiwonetsere momwe mthupi alili panopo. Ndikopera-kopatsa, ndi kosavuta kufalitsa uthenga ndi kunyalanyaza kuti uyikonzere.
Mwachitsanzo, taganizirani ndondomeko yotsatira ya wodwala kuchipatala chifukwa cha chibayo omwe amayamba kutupa kwala kumanzere pa tsiku lachitatu la chipatala.
Dokotala yemwe akupezekapo amalamulira ultrasound kuti adziwe ngati mwendo ukutupa ndi chifukwa chakuya kwa thrombosis ( magazi ). Chidulechi pamapeto a zolemba za dokotala chikuphatikizapo kufotokoza chithandizo cha chibayo cha wodwalayo komanso mawu otsatirawa:
"Mwendo wakumanzere ukutupa. Dokotala wa Doppler ultrasound analamula. "
Pambuyo pake tsiku limenelo, dokotala amadziwa kuti ultrasound ndi yoipa.
Tsiku lotsatira, pofuna kusunga nthawi, amagwiritsira ntchito ntchito yophatikizapo ndikuikapo chidule chomwecho kuyambira tsiku lapitalo kupita m'ndandanda. Koma iye amanyalanyaza kuti asinthidwe chilembacho ndi zotsatira za ultrasound.
Popeza sanasinthe mfundoyi, zolembazo zatha nthawi yambiri ndipo zakhala zosavomerezeka. Imanena kuti mphamvu ya ultrasound "yalamulidwa," koma ultrasound yakhala ikuchitidwa ndipo zotsatira zimadziwika.
Zochepa ndi Zochepa Zolemba za EHR Zinalowa Mwadongosolo
Zokwanira, zolemba zachipatala zosayenera zingakhudze chitetezo cha odwala, makamaka pamene ena am'chipatala (monga akatswiri ndi alangizi) amadalira pazomwe akuyenera kukumbukira kuti wodwala akupita patsogolo. Zowonjezera zolakwika zimachulukitsidwa ngati mbiri yosadziwika ikufalitsidwa mu mbiri yonse ya wodwalayo mu EHR ndi machitidwe ena okhudzana ndi zaumoyo.
Vutoli likhoza kuchitika m'mabuku odwala komanso odwala. Mu 2013, pulofesa wothandizira Daryl Thornton wa University of Case Western Reserve ku Cleveland adatsogolera kafukufuku amene anapeza 82 peresenti ya zolemba mu chipatala chokwanira chomwe amachiritsidwa ndi madokotala (omwe amaphunzitsidwa) ndipo 74 peresenti ya madokotala omwe amaphunzitsidwa. osachepera 20 peresenti adakopera zambiri mu gawo lomwe liri ndi ndondomeko ndi ndondomeko.
Mu August 2017, kafukufuku adafalitsidwanso mu Journal of the American Medical Association (JAMA) yomwe inasonyeza kuti zinthu zokhudzana ndi zolemba ndi zolemba zikudandaula kuti zisafike lero. Ofufuza kuchokera ku yunivesite ya California, ku San Francisco, anafufuza kafukufuku wopita kuchipatala wolembedwa ndi odwala 460 kwa miyezi 8. Iwo anatsimikizira kuti zosakwana zosakwana zisanu ndi chimodzi mwazolembazo zinalowetsedwamo. Kawirikawiri, madokotala ankakopera kapena kuitanitsa zolemba zawo. Nzika zinkakonda kugwiritsa ntchito njirazi mobwerezabwereza kuposa ophunzira a zachipatala, omwe poyamba ankalowetsa magawo 10 pa magawo khumi a zolemba zawo pamanja.
Chinthu chinanso chosokoneza bukuli ndi chakuti zimalepheretsa madokotala kukhala ndi luso loganiza bwino pofufuza, kufotokoza mwachidule komanso kulemba udindo wa wodwalayo.
Pogwiritsa ntchito kapepala, mapepala apambali angamasulidwe mosavuta ndi mauthenga osakanikirana, osatuluka nthawi zonse pobisa mfundo zofunika kwambiri zokhudza mkhalidwe wa wodwalayo.
Gwiritsani Ntchito Zopindulitsa Kwambiri pa Zowopsa za Mzere
American Health Information Management Association imalimbikitsa kuti " Kugwiritsira ntchito ntchito yolemba / kulumikiza mu EHRs kuyenera kuloledwa pokhapokha pokhala ndi mphamvu zogwira ntchito ndi zachitukuko zomwe zikuphatikizapo ndondomeko za bungwe ndi ndondomeko, zoyenera kuti zitha kutenga nawo mbali pa maphunziro a umisiri ndi maphunziro, ndi kuwonetseratu kochitika . "
Ngakhale kuti zolemba zowonjezera zikhoza kuwonjezeka bwino pazinthu zina, phindu liyenera kuyeneredwa kuti likhale lopangidwa ndi nthawi, zolakwika komanso zosafunikira nthawi zambiri mu EHR.
Kuonjezera chitetezo cha odwala komanso khalidwe la zolembera, njira zosiyanasiyana zakhala zikuperekedwa. Mwachitsanzo, motsatira ndondomeko zamakono zamakono ndi zipangizo zamakono, zokopera ndi zoitanitsa zomwe zilipo ziyenera kudziwika momveka bwino ndi wolemba woyambirira, nthawi ndi tsiku lolowa. Komanso, wolemba womaliza ayenera kuzindikira kuti iye ali ndi udindo pa zonse zomwe zili mu chikalata choletsedwa. Izi ziyenera kulimbikitsa odwala kuti azisintha mosamalitsa ndikuwerenganso zolemba zawo. Mabungwe akuluakulu a zaumoyo ambiri akuletsanso kapena kuletsa ophunzira kuti azilemba zolemba.
Kawirikawiri, njira yoganizira ndi yowonetsera yakomera, yomwe iyenera kuphatikizapo maphunziro a ogwira ntchito ndi kufufuza mosamalitsa zolemba.
> Zotsatira:
> Patterson E, Sillars D, Moffatt-Bruce S, et al. Zolinga Zomwe Mungagwiritse Ntchito Pogwiritsira Ntchito Zopititsa Pamodzi ndi Mapepala Achikulire Achidwi Mumapangidwe a Chipatala. Jt Com J Wodwala Safari . 2017; 43: 375-385.
> American Health Information Management Association. Gwiritsani Ntchito Koyenera ndi Kuyika Kugwira Ntchito mu Mauthenga a Health Electronic. 2014.
> Thornton JD, Schold JD, Venkateshaiah L, Lander B. Kufalikira kwa Zopangidwe Zophiphiritsira ndi Opezekapo ndi Okhala M'njira Zachidwi Zotsatira Zowonjezera. Crit Care Med . 2013; 41 (2): 382-8. do: 10.1097 / CCM.0b013e3182711a1c.
> Wang M, Khanna R, Najafi N. Kuwonetsera Gwero la Malembo muzolemba Zachipatala za Zaumoyo za Edzi. JAMA Internal Medicine . 2017; 177 (8): 1212-1213.
> Weis J, Levy P. Nkhani mu Practice Management: Copy, Paste, ndi Cloned Notes mu Electronic Health Records. Chifuwa . 2014; 145: 632-638.