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Optimizing the electronic medical record to improve patient care and conduct quality improvement initiatives in a concussion specialty clinic.
Simon, Kelly Claire; Reams, Nicole; Beltran, Erik; Wang, Charles; Hadsell, Bryce; Maurer, Darryck; Hillman, Laura; Tideman, Samuel; Garduno, Lisette; Meyers, Steven; Frigerio, Roberta; Maraganore, Demetrius M.
Afiliación
  • Simon KC; Department of Neurology, NorthShore University HealthSystem, Evanston, Illinois, USA.
  • Reams N; Department of Neurology, NorthShore University HealthSystem, Evanston, Illinois, USA.
  • Beltran E; Department of Neurology, NorthShore University HealthSystem, Evanston, Illinois, USA.
  • Wang C; Department of Neurology, NorthShore University HealthSystem, Evanston, Illinois, USA.
  • Hadsell B; Health Information Technology, NorthShore University HealthSystem, Evanston, Illinois, USA.
  • Maurer D; Health Information Technology, NorthShore University HealthSystem, Evanston, Illinois, USA.
  • Hillman L; Health Information Technology, NorthShore University HealthSystem, Evanston, Illinois, USA.
  • Tideman S; Health Information Technology, NorthShore University HealthSystem, Evanston, Illinois, USA.
  • Garduno L; Department of Neurology, NorthShore University HealthSystem, Evanston, Illinois, USA.
  • Meyers S; Department of Neurology, NorthShore University HealthSystem, Evanston, Illinois, USA.
  • Frigerio R; Department of Neurology, NorthShore University HealthSystem, Evanston, Illinois, USA.
  • Maraganore DM; Department of Neurology, University of Florida, Gainesville, Florida, USA.
Brain Inj ; 34(1): 62-67, 2020.
Article en En | MEDLINE | ID: mdl-31644325
Objective: To use the electronic medical record (EMR) to optimize patient care, facilitate documentation, and support quality improvement and practice-based research in a concussion (mild traumatic brain injury; mTBI) clinic.Methods: We built a customized structured clinical documentation support (SCDS) toolkit for patients in a concussion specialty clinic. The toolkit collected hundreds of fields of discrete, standardized data. Autoscored and interpreted score tests include the Generalized Anxiety Disorder 7-item scale, Center for Epidemiology Studies Depression scale, Insomnia Severity Index, and Glasgow Coma Scale. Additionally, quantitative score measures are related to immediate memory, concentration, and delayed recall. All of this data collection occurred in a standard appointment length.Results: To date, we evaluated 619 patients at an initial office visit after an mTBI. We provided a description of our toolkit development process, and a summary of the data electronically captured using the toolkit.Conclusions: The electronic medical record can be used to effectively structure and standardize care in a concussion clinic. The toolkit supports the delivery of care consistent with Best Practices, provides opportunities for point of care decision support, and writes comprehensive progress notes that can be communicated to other providers.
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Texto completo: 1 Colección: 01-internacional Base de datos: MEDLINE Asunto principal: Conmoción Encefálica / Registros Electrónicos de Salud Tipo de estudio: Diagnostic_studies / Guideline / Prognostic_studies Límite: Humans Idioma: En Revista: Brain Inj Asunto de la revista: CEREBRO Año: 2020 Tipo del documento: Article País de afiliación: Estados Unidos Pais de publicación: Reino Unido
Texto completo
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Texto completo: 1 Colección: 01-internacional Base de datos: MEDLINE Asunto principal: Conmoción Encefálica / Registros Electrónicos de Salud Tipo de estudio: Diagnostic_studies / Guideline / Prognostic_studies Límite: Humans Idioma: En Revista: Brain Inj Asunto de la revista: CEREBRO Año: 2020 Tipo del documento: Article País de afiliación: Estados Unidos Pais de publicación: Reino Unido