دورية أكاديمية
Differences Between What Is Said During the Consultation and What Is Recorded in the Electronic Health Record.
| العنوان: | Differences Between What Is Said During the Consultation and What Is Recorded in the Electronic Health Record. |
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| المؤلفون: | Lacroix-Hugues V; Université Côte d'Azur, Département d'enseignement et de recherche en médecine générale, Nice, France.; CHU de Nice, Département de Santé Publique, Nice, France., Azincot-Belhassen S; Université Côte d'Azur, Département d'enseignement et de recherche en médecine générale, Nice, France., Staccini P; Université Côte d'Azur, Département d'Ingénierie du Risque et Informatique de Santé, Nice, France., Darmon D; Université Côte d'Azur, Département d'enseignement et de recherche en médecine générale, Nice, France. |
| المصدر: | Studies in health technology and informatics [Stud Health Technol Inform] 2019 Aug 21; Vol. 264, pp. 674-678. |
| نوع المنشور: | Journal Article |
| اللغة: | English |
| بيانات الدورية: | Publisher: IOS Press Country of Publication: Netherlands NLM ID: 9214582 Publication Model: Print Cited Medium: Internet ISSN: 1879-8365 (Electronic) Linking ISSN: 09269630 NLM ISO Abbreviation: Stud Health Technol Inform |
| أسماء مطبوعة: | Original Publication: Amsterdam ; Washington, DC : IOS Press, 1991- |
| مواضيع طبية MeSH: | Electronic Health Records* , General Practitioners*, Humans ; Referral and Consultation |
| مستخلص: | Electronic Health Records (EHRs) can be used for research but this raises the problem of data quality. Objective: To evaluate the quality of the information recorded in an EHR by a general practitioner (GP) during a regular office consultation. Method: 191 dialogs between the GP and patient were recorded and translated into the International Classification of Primary Care Second edition (ICPC-2) codes. Written information of the corresponding EHR was extracted and coded for comparison. Results: The primary reason for the consultation was recorded in the EHR in 41.2% of the cases and the diagnosis in 44.1% of the cases. Diagnoses noted in the EHR were less often communicated to the patients than the primary reasons (p<0.0001). Conclusion: There is a loss of information between the dialog during a consultation and what is reported in the EHR. Consequences in terms of continuity and safety of care can be expected. |
| فهرسة مساهمة: | Keywords: Electronic Health Records; Information Management; Self Report |
| تواريخ الأحداث: | Date Created: 20190824 Date Completed: 20190911 Latest Revision: 20190911 |
| رمز التحديث: | 20240628 |
| DOI: | 10.3233/SHTI190308 |
| PMID: | 31438009 |
| قاعدة البيانات: | MEDLINE |
| تدمد: | 1879-8365 |
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| DOI: | 10.3233/SHTI190308 |