Kupararira kwenguva yakareba, mashoko asina kururama
Kopa-kuisa ndeimwe yemabasa anonyanya kukosha anowanikwa kuvashandisi vepi zvinyorwa zvekunyora magwaro. Vanachiremba vanoshandisa marekodhi ezvehutano zvehutano (EHRs) kunyora mashoko ehutano hwehutano hwekuona. Zvinhu zvakadai zvinosanganisira zviratidzo izvo murwere ari kuzivisa, kuongorora muviri, mhinduro dzekuedza, kuongororwa, kuongorora uye zvirongwa zvekurapa. Kana dambudziko remurwere richidzoka kana risingaperi, chiremba anoda kunyora zvinyorwa zvechinetso chimwechete pane zvakadzokororwa.
Kuti uwedzere kubudirira, chiremba angashandisa kopi-paste kuti ipe zvikamu zvepamusoro zvemashoko kubva kune rimwe rekodhi kusvika kune rinotevera.
Nepo copy-paste iyo iri nyore nyore kumakiriniki akabatikana, inogona kutungamirira kune zvikanganiso zvisina kururama, zvinotsausa uye zvinogona kuipa muEHR . Kunetseka kwakakonzerwawo navanachiremba vachishandisa kopi-kuisa uye kunyorera-mberi mumashizha ekuyerera, zvichiita kuti zvingave zvisiri izvo kana kuti zvisingashandisi nguva inoendeswa mberi. Ichi chinyorwa chichatarisa pamakirini emakiriniki asina kukodzera kopi-paste.
Mashoko Akapererwa Anobatsira Kutarisira Mwoyo Murefu
Dambudziko guru nderokuti ruzivo rwaimbova rwakarurama runo husina kururama kana rusina kuongororwa kuti ruratidze mamiriro ekurarama kwemu murwere. Nekopi-paste, zviri nyore zvikuru kuparadzira ruzivo uye kusaregererwa kuigadzirisa.
Somuenzaniso, funga kutsanangurwa kunotevera kwechiremba muchipatara nokuda kwepineumonia inokura kukurira kwegumbo roruboshwe pazuva rechitatu rechipatara.
Chiremba anoshanda achiraira an ultrasound kuti aone kana gumbo rinenge richikurira rinokonzerwa nehupamhi hwehuputi hwemhepo ( ropa clot ). Mhedziso pfupi pamagumo echinyorwa chechiremba inosanganisira kutsanangurwa kwehutano hwemurwere wepumumumu pamwe neshoko rinotevera:
"Ruoko rworuboshwe ruchivhuvhuta. Venous Doppler ultrasound akarayirwa. "
Gare gare zuva iroro, chiremba anoziva kuti ultrasound haina kunaka.
Zuva rakatevera, kuitira kuchengetedza nguva, anoshandisa kopi-kuisa basa uye anoisa pfupiso imwechete mazwi kubva pazuva rakapinda kupinda muhope. Asi iye anorega kugadzirisa chinyorwa chacho nemigumisiro ye ultrasound.
Sezvo asina kuvandudza ruzivo, iko rekodha ikozvino kusati kwamboitika uye naizvozvo hazvina kururama. Iyo inotaura kuti chimiro che ultrasound "chakarairwa," asi iyo ultrasound yakanyatsoitwa uye mhinduro yacho inozivikanwa.
Chishomanana uye Chisinganyanyi EHR Nhepfenyuro Dzapinda Mazano
Zvisizvo, zvinyorwa zvisina kukodzera zvezvokurapa zvinogona kukanganisa kuchengetedzwa kwevarwere, kunyanya apo vamwe vakiriniki (sevanyanzvi nevadzidzisi) vanovimba neshoko kuti varambe vachisangana nehuwandu hwemurwere. Izvo zvingaita kukanganisa zvinowedzera kana ruzivo rwakashata rwakapararira muhutano hwevarwere mune EHR uye mamwe maitiro ehutano hwehutano hwehutano.
Dambudziko iri rinogona kuitika muchipatara uye kunze kwemashoko. Muna 2013, mubatsiri wepurofesa Daryl Thornton weCall Western Reserve University muCleveland akatungamirira chidzidzo chakawana 82 muzana yezvinyorwa mune imwe nhengo yezvokuchengetedza yakawanda yakagadzirwa nevarapi vanogara (pakudzidzisa) uye 74 muzana yezvinyorwa zvakagadzirwa nekuenda kune vanachiremba (zvakadzidziswa zvakakwana) vanenge 20 muzana vakakopera mashoko munharaunda ine chekuongorora uye chirongwa.
MunaAugust 2017, chidzidzo chakanga chakabudiswawo mu Journal of the American Medical Association (JAMA) iyo yakaratidza mamiriro ezvinhu ane chokuita nekunyora-uye-kusungiridza inoramba ichizvidya mwoyo kusvika nhasi. Vatsvakurudzi vanobva kuYunivhesiti yeCalifornia, San Francisco vakaongorora zvirwere zvokufambira mberi zvepatient zvakanyorerwa navanachiremba 460 kwemakore gumi nemana. Vakagumisa kuti kudarika chikamu chimwe chete kubva kune chechishanu chemapepa chakanga chapinda. Kazhinji, vanachiremba vaikopa kana kutumira zvinyorwa zvavo. Vagari vakashandisa nzira idzi kakawanda kupfuura vadzidzi vezvokurapa, avo vekare vaipinda zvinopfuura 10 muzana zvezvinyorwa zvavo.
Rimwe risina kunaka rekopi-kunyanya ndechokuti rinodzivisa vanachiremba kuti vashandise unyanzvi hunofunga hwokufunga mukuongorora, kufupikisa nekukurukura chinzvimbo chemu murwere pane zvinyorwa.
Nekopi-paste, kufambira mberi kwemashoko kunogona kuvharidzirwa nyore nyore neyekudzivirira, ruzivo rwakapedzisira kuitika panguva yekuvhara zvinhu zvakakosha zvikuru pamusoro pemamiriro emurwere.
Nzira Yakanakisisa Nyaya dzeCharb Risks
IAmerican Health Information Management Association inokurudzira kuti " Kushandiswa kwekodha / kushandiswa kwemabasa muEHRs kunofanirwa kubvumirwa chete muhupo hwehutano hwakasimba hwehutungamiri nehutungamiri hunosanganisira masangano ehurongwa nemitemo, zvinoda kubatanidzwa mukushandiswa kwevashandi uye dzidzo, uye kuenderera mberi . "
Kunyange zvazvo kukopa-kuisa kunogona kuwedzerwa kubudirira mune mamwe mamiriro ezvinhu, zvikwereti zvinoda kuyerwa nezvakakwanisa kugadzira nguva dzisati dzaitika, dzisina kururama uye dzisina kukodzera mabhuku matsvene muEHR.
Kuwedzera kuchengetedzwa kwevarwere nehuwandu hwezvinyorwa, nzira dzakasiyana dzakagadzirirwa. Semuenzaniso, maererano nezviripo zvezvipatara uye zvigadziriswa, zvinyorwa uye zvinyorwa zvinyorwa zvinofanira kuve zvakajeka uye munyori wepakutanga, nguva uye zuva rekupinda rakaratidzwa. Uyewo, munyori wekupedzisira anoda kuziva kuti iye ndiye ane mhosva yezvose zviri mudhipi yakasayirwa. Izvi zvinofanira kukurudzira vanachiremba kuti vaongorore zvinyorwa uye vaongorore manotsi avo. Nzvimbo dzakawanda dzekuchengetedza hutano ikozvino dzinodzivisa kana kudzivirira vadzidzi kuti varege kunyora manotsi.
Kazhinji, nzira inofungidzirwa uye yakaenzana yakaropafadzwa, iyo inoda kusanganisira vadzidzisi vedzidzo uye kunyatsoongorora zvinyorwa.
> Sources:
> Patterson E, Sillars D, Moffatt-Bruce S, et al. Nzira Yakachengeteka Zvinyorwa zveKushandiswa kweKopa-Kuendesa neUniteding Flow Sheets muPirisa Zvirongwa. Jt Com J Qual Mutezo Saf . 2017; 43: 375-385.
> IAmerican Health Information Management Association. Kushandisa Zvakakodzera Kopi uye Kushandiswa Kwebasa muElectronic Health Records. 2014.
> Thornton JD, Schold JD, Venkateshaiah L, Lander B. Kuwandisa kweKunyorwa kweChirangaridzo kuburikidza nekupinda uye vagari vepanhau mukunyatsotarisirwa. Crit Care Med . 2013; 41 (2): 382-8. doi: 10.1097 / CCM.0b013e3182711a1c.
> Wang M, Khanna R, Najafi N. Kufananidza Mhedziso yeMagwaro muMutambo Wemutano Nyaya Dzokufambira Mberi. JAMA Internal Medicine . 2017; 177 (8): 1212-1213.
> Weis J, Levy P. Misoro mu Practice Management: Copy, Paste, uye Cloned Notes mu Electronic Health Records. Chest . 2014; 145: 632-638.