不间断的工具,以支持提供者营养不良的文件,并尽量减少文件查询。

IF 3.4 Q2 HEALTH CARE SCIENCES & SERVICES
JAMIA Open Pub Date : 2025-05-21 eCollection Date: 2025-06-01 DOI:10.1093/jamiaopen/ooaf034
Kevin O'Malley, Patricia Dasch, Sarah C Bauer, Dhananjay Vaidya, Matthew Severson, Sam Sokolinsky, Patricia Kaehne, Peter M Hill, Daniel J Brotman, Benjamin Erwin Bodnar, Stephen Lichtenstein, Renee Demski, Stephen A Berry
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引用次数: 0

摘要

目的:确定电子文档工具是否可以在不影响诊断编码的情况下减少对营养不良的文档查询。材料与方法:比较两组600名内科出院的营养不良成人在推广该电子营养不良记录工具前后的营养不良记录查询和诊断编码比例。结果:在干预前和干预后分别有300例(50%)和112例(19%)患者对营养不良的记录进行了查询。结论:我们已经证明,引入和推广这种电子记录工具可以减少对营养不良的查询,同时保留诊断编码。
本文章由计算机程序翻译,如有差异,请以英文原文为准。

Noninterruptive tool to support provider malnutrition documentation and minimize documentation queries.

Noninterruptive tool to support provider malnutrition documentation and minimize documentation queries.

Noninterruptive tool to support provider malnutrition documentation and minimize documentation queries.

Objectives: Determine if an electronic documentation tool can reduce documentation queries for malnutrition without impacting diagnostic coding.

Materials and methods: Malnutrition documentation queries and diagnosis coding proportions were compared between 2 groups of 600 malnourished adults discharged from internal medicine services before and after this electronic malnutrition documentation tool was promoted.

Results: Documentation queries for malnutrition were observed in 300 (50%) of the preintervention discharges and 112 (19%) of the postintervention discharges (P < .001). A diagnosis code for malnutrition was observed in 99% of both groups. In a logistic regression accounting for clustering by provider, the odds ratio of a query postdeployment vs predeployment was 0.21 (95% CI, 0.16-0.29). In 88 of 112 (79%) of the postintervention discharges queried for malnutrition, the tool was not used as recommended.

Conclusions: We have demonstrated that introducing and promoting this electronic documentation tool can reduce querying for malnutrition while preserving diagnostic coding.

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来源期刊
JAMIA Open
JAMIA Open Medicine-Health Informatics
CiteScore
4.10
自引率
4.80%
发文量
102
审稿时长
16 weeks
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