Isakaza isikhathi esingaphansi, ulwazi olungalungile
Ukukopisha-ukunamathisela kungenye yemisebenzi ewusizo kakhulu etholakalayo kubasebenzisi kunoma iyiphi indlela yamadokhumenti e-electronic. Odokotela basebenzisa amarekhodi ezempilo e-electronic (EHRs) ukuze babhale imininingwane yokuhlangana kwezempilo. Imininingwane enjalo ihlanganisa izimpawu isiguli esibikayo, ukuhlolwa ngokomzimba, imiphumela yokuhlola, ukuxilongwa, ukuhlolwa kanye nokwelapha izinhlelo. Uma inkinga yesiguli iphindaphinda noma ingapheli, udokotela udinga ukubhala izibuyekezo zenkinga efanayo ngokuphindaphindiwe.
Ukuze ukwandise ukusebenza kahle, umtholampilo angasebenzisa ikhophi-unamathisele ukuletha izingxenye zomqulu ezivela kwirekhodi elilodwa kuya elilandelayo.
Ngenkathi ikhophi-unamathisela ithuluzi elihle labamtholampilo abamatasa, kungaholela emaphutha angalungile, akhohlisa futhi angase abe yingozi ku- EHR . Ukukhathazeka kuye kwaphakanyiswa nabahlengikazi besebenzisa ikhophi-ukunamathisela nokukopisha phambili emaphepheni, okuholela ekungeneni kolwazi olungalungile noma oluphelelwe isikhathi. Lesi sihloko sizogxila emigodini yemitholampilo yekhophi-yokunamathisela engalungile.
Ulwazi olungaphelelwe isikhathi oluthinta ukunakekelwa kwesineke
Inkinga enkulu ukuthi ulwazi olwaluke lube lulungile luba olungalungile uma lubuyekezwa ukuze lubonise isimo samanje sesiguli. With ikhophi-unamathisele, kulula kakhulu ukusabalalisa ulwazi nokunganaki ukuyibuyekeza.
Ngokwesibonelo, cabanga ngencazelo elandelayo yesiguli esibhedlela ngenxa ye- pneumonia eqala ukuvuvukala komlenze wesobunxele ngosuku lwesithathu esikoleni esibhedlela.
Udokotela oya khona uyalela i-ultrasound ukuthi anqume ukuthi ukugoba komlenze kungenxa ye-thrombosis ejulile (i- clot yegazi ). Isifinyezo esifushane ekugcineni kwesaziso sodokotela sihlanganisa incazelo yesifo somuthi we- pneumonia kanye nesitatimende esilandelayo:
"Umlenze wesobunxele uvunguza. I-Venous Doppler ultrasound iyalwe. "
Kamuva ngalolo suku, udokotela ufunda ukuthi i-ultrasound ayibi.
Ngolunye usuku olulandelayo, ukuze ulondoloze isikhathi, usebenzisa umsebenzi wokukopisha-unamathisela futhi ufaka isitatimende esifinyeto esifanayo kusukela ngosuku oludlule kuya encwadini. Kodwa uyakwazisa ukuvuselela inothi ngemiphumela ye-ultrasound.
Njengoba engazange avuselele ulwazi, irekhodi seliphelelwe yisikhathi futhi ngakho-ke alilungile. Ithi isimo se-ultrasound "siyalwe," kepha i-ultrasound iye yenziwa ngempela futhi imiphumela yaziwa.
Okumbalwa futhi Okungenani Amanothi e-EHR angene ngesandla
Ukuphelelwa yisikhathi, amarekhodi wezokwelapha angalungile angathinta ukuphepha kwesiguli, ikakhulukazi uma abanye ochwepheshe bezempilo (njengabachwepheshe kanye nababonisi) bathembele encwadini ukuze baqhubeke nokuhambisana nenqubekela phambili yesiguli. Ikhono lephutha landa uma ulwazi olungalungile lusakazwa kulo lonke irekhodi lesiguli ku-EHR nakwezinye izinhlelo zokuxhumana zezempilo.
Le nkinga ingenzeka kumarekhodi wezitho zokwelapha neziguli. Ngo-2013, uprofesa wothisha uDaryl Thornton we-Case Western Reserve University eCleveland uholele ucwaningo oluthola amaphesenti angama-82 amanothi ekamelweni lokunakekelwa okunzulu eladalwa odokotela abahlala kulo (ekuqeqeshweni) kanye namaphesenti angama-74 amanothi adalwe ngokuya kudokotela (abaqeqeshwe ngokugcwele) okuqukethwe okungenani amaphesenti angu-20 akopishe ulwazi kulesi sigaba esinokuhlola nokuhlela.
Ngo-Agasti 2017, isifundo sabuye sanyatheliswa kuyi-Journal of the American Medical Association (JAMA) esibonise isimo esiphathelene nemininingwane yokukopisha nokunamathisela isalokhu sikhathazeka kuze kube yimanje. Abacwaningi abavela eNyuvesi yaseCalifornia, eSan Francisco bahlaziya amanothi okuqhubekayo okugula iziguli ezibhalwe abahlengikazi abangu-460 esikhathini esingangezinyanga ezingu-8. Baphetha ngokuthi okungaphansi kweyodwa kweyesihlanu kwamanothi kufakwe ngesandla. Ngokuvamile, odokotela bakopisha noma bangenisa ukungena kwabo. Izakhamuzi zasebenzisa lezi zindlela ngokuphindaphindiwe kunezifundiswa zezokwelapha, zangaphambili ezingena amaphesenti angaphezu kwezingu-10 zamanothi abo ngesandla.
Okunye ukungalungi kwekhophi-yokunamathisela ukuthi kudambisa odokotela ukuba bangasebenzisi amakhono okucabanga okubalulekile ekuhlaziyeni, ngokufingqa kanye nokukhuluma ngesimo sesiguli emanothini okuqhubekayo.
Ngekhophi-unamathisele, amanothi okuqhubekayo angakwazi ukuvinjelwa kalula ngolwazi olungapheli, olungaphelelwa isikhathi ngenkathi efihla imininingwane ebaluleke kakhulu ngesimo sesiguli.
Izincomo ezisebenzayo ezinhle kakhulu kwizinkinga zekhawunt
I-American Health Information Management Association incoma ukuthi " Ukusetshenziswa komsebenzi wokukopisha / wokunamathisela ku-EHR kufanele kuvunyelwe kuphela lapho kukhona khona ukulawula okuqinile kwezobuchwepheshe nokuphatha okubandakanya izinqubomgomo zenqubo kanye nezinqubo, izidingo zokubamba iqhaza ekuqeqesheni komsebenzisi kanye nemfundo, nokuqapha okuqhubekayo . "
Ngenkathi ikhophi-yokunamathisela ingathuthukisa ukusebenza kahle kwezinye izimo ezithile, izinzuzo zidinga ukulinganiswa ngokusemandleni okudala isikhathi esingaphansi kwesikhathi, imibhalo engalungile futhi engadingekile e-EHR.
Ukwandisa ukuphepha kwesiguli kanye nekhwalithi yamanothi, amasu ahlukene aphakanyisiwe. Isibonelo, ngokuhambisana nezinqubomgomo zamanje zezibhedlela nezikhungo, okuqukethwe okukopishiwe nokungeniswa kufanele kubonakale ngokucacile futhi umbhali wangempela, isikhathi nosuku lokungena kuphawulwe. Futhi, umbhali wokugcina udinga ukuqaphela ukuthi unesibopho sayo yonke into yedokhumenti esayiniwe. Lokhu kufanele kukhuthaze odokotela ukuba babuyekeze ngokucophelela futhi babuyekeze amanothi abo. Izikhungo eziningi zokunakekelwa kwempilo manje zivimbela noma zivimbela abafundi ukuba bakopishe amanothi.
Ngokuvamile, indlela ecatshangelwe futhi elinganisiwe iye yathandwa, okudingeka ihlanganise imfundo yabasebenzi nokuqapha ngokucophelela amanothi.
> Imithombo:
> Patterson E, uSillars D, uMoffatt-Bruce S, et al. Izincomo Zokuzivikela Eziphephile Zokusetshenziswa Kwekhophi-Ukuhambisa Amashidi Okugeleza Abahlengikazi Ezilungiselelweni Zezibhedlela. Jt Com J Qual Isiguli Sokuphepha . 2017; 43: 375-385.
> I-American Health Information Management Association. Ukusetshenziswa Okufaneleko Kokusebenza Kokukopisha Nokunamathisela kumarekhodi wezeMpilo e-Electronic. 2014.
> Thornton JD, uSchold JD, Venkateshaiah L, uLander B. Ukuvama kokwaziswa okuqoshiwe ngokubanjelwa kanye nabahlali emanothini okuHlola okuNgcono. Crit Care Med . 2013; 41 (2): 382-8. i-doi: 10.1097 / CCM.0b013e3182711a1c.
> Wang M, uKhanna R, Najafi N. Echaza Umthombo Wombhalo Emanothi Okuthuthukiswa Kwamakholi E-Electronic Health. I-JAMA Imithi Yangaphakathi . 2017; 177 (8): 1212-1213.
> Weis J, Levy P. Izihloko ku-Practice Management: Kopisha, Namathisela, namanothi ekhonjiwe kumarekhodi e-Electronic Health. Isifuba . 2014; 145: 632-638.