The Electronic Health Record and the Clinical Examination

被引：8
作者：
Hedian, Helene F. [1 ]
Greene, Jeremy A. [2 ,3 ]
Niessen, Timothy M. [4 ]
机构：
[1] Johns Hopkins Univ, Sch Med, Div Gen Internal Med, 10753 Falls Rd,Suite 325, Lutherville Timonium, MD 21093 USA
[2] Johns Hopkins Univ, Sch Med, Dept Med, 1900 East Monument St,Welch 324, Baltimore, MD 21205 USA
[3] Johns Hopkins Univ, Sch Med, Dept Hist Med, 1900 East Monument St,Welch 324, Baltimore, MD 21205 USA
[4] Johns Hopkins Univ, Sch Med, Hospitalist Program, Div Gen Internal Med, Meyer 8-134-H,600 North Wolfe St, Baltimore, MD 21287 USA
来源：
MEDICAL CLINICS OF NORTH AMERICA | 2018年 / 102卷 / 03期
关键词：
Clinical examination; Electronic health record; EHR; Doctor-patient relationship; Physical examination; History; RADIOLOGY REQUEST FORMS; RESIDENTS SPEND; SOCIAL MEDIA; PATIENT; DOCUMENTATION; IMPACT; PHYSICIANS; HISTORY; EMR; COMPUTERS;
D O I：
10.1016/j.mcna.2017.12.009
中图分类号：
R5 [内科学];
学科分类号：
1002 ; 100201 ;
摘要：
This article examines how the adoption of the electronic health record (EHR) has changed the most fundamental unit of medicine: the clinical examination. The impact of the EHR on the clinical history, physical examination, documentation, and the doctor-patient relationship is described. The EHR now has a dominant role in clinical care and will be a central factor in clinical work of the future. Conversation needs to be shifted toward defining best practices with current EHRs inside and outside of the examination room.
引用
收藏
页码：475 / +
页数：10
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