Enhancing Clinical History Taking Through the Implementation of a Streamlined Electronic Questionnaire System at a Pediatric Headache Clinic: Development and Evaluation Study DOI Creative Commons
Jaeso Cho, Ji Yeon Han, Anna Cho

et al.

JMIR Medical Informatics, Journal Year: 2024, Volume and Issue: 12, P. e54415 - e54415

Published: Nov. 8, 2024

Abstract Background Accurate history taking is essential for diagnosis, treatment, and patient care, yet miscommunications time constraints often lead to incomplete information. Consequently, there has been a pressing need establish system whereby the questionnaire duly completed before medical appointment, entered into electronic health record (EHR), stored in structured format within database. Objective This study aimed develop evaluate streamlined system, BEST-Survey (Bundang Hospital Electronic System Total Care-Survey), integrated with EHR, enhance data management patients pediatric headaches. Methods An was developed at Seoul National University Bundang Hospital, allowing complete previsit questionnaires on tablet PC. The information automatically EHR database further analysis. A retrospective analysis compared clinical acquired from aged <18 years visiting neurology outpatient clinic headaches, after implementing system. included 365 452 implementation. Answer rates positive of key headache characteristics were between 2 groups system’s utility. Results Implementation significantly increased mean acquisition rate 54.6% 99.3% ( P< .001). Essential features such as onset, location, duration, severity, nature, frequency obtained over 98.7% (>446/452) implementation, 53.7% (196/365) 85.2% (311/365) before. facilitated comprehensive collection, enabling detailed population. Most (280/452, 61.9%) reported onset less than 1 year prior, temporal region being most common pain location (261/703, 37.1%). Over half (232/452, 51.3%) experienced headaches lasting hours, nausea vomiting commonly associated symptoms (231/1036, 22.3%). Conclusions markedly improved completeness accuracy items also extraction research purposes. While cannot replace physician-led taking, it serves valuable adjunctive tool care.

Language: Английский

Enhancing Clinical History Taking Through the Implementation of a Streamlined Electronic Questionnaire System at a Pediatric Headache Clinic: Development and Evaluation Study DOI Creative Commons
Jaeso Cho, Ji Yeon Han, Anna Cho

et al.

JMIR Medical Informatics, Journal Year: 2024, Volume and Issue: 12, P. e54415 - e54415

Published: Nov. 8, 2024

Abstract Background Accurate history taking is essential for diagnosis, treatment, and patient care, yet miscommunications time constraints often lead to incomplete information. Consequently, there has been a pressing need establish system whereby the questionnaire duly completed before medical appointment, entered into electronic health record (EHR), stored in structured format within database. Objective This study aimed develop evaluate streamlined system, BEST-Survey (Bundang Hospital Electronic System Total Care-Survey), integrated with EHR, enhance data management patients pediatric headaches. Methods An was developed at Seoul National University Bundang Hospital, allowing complete previsit questionnaires on tablet PC. The information automatically EHR database further analysis. A retrospective analysis compared clinical acquired from aged <18 years visiting neurology outpatient clinic headaches, after implementing system. included 365 452 implementation. Answer rates positive of key headache characteristics were between 2 groups system’s utility. Results Implementation significantly increased mean acquisition rate 54.6% 99.3% ( P< .001). Essential features such as onset, location, duration, severity, nature, frequency obtained over 98.7% (>446/452) implementation, 53.7% (196/365) 85.2% (311/365) before. facilitated comprehensive collection, enabling detailed population. Most (280/452, 61.9%) reported onset less than 1 year prior, temporal region being most common pain location (261/703, 37.1%). Over half (232/452, 51.3%) experienced headaches lasting hours, nausea vomiting commonly associated symptoms (231/1036, 22.3%). Conclusions markedly improved completeness accuracy items also extraction research purposes. While cannot replace physician-led taking, it serves valuable adjunctive tool care.

Language: Английский

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