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Related Experiment Videos

A comparison of problem lists generated by physicians, nurses, and patients: implications for CPR systems

S B Henry1, W L Holzemer

  • 1School of Nursing, University of California, San Francisco, USA.

Proceedings. Symposium on Computer Applications in Medical Care
|January 1, 1995
PubMed
Summary

Physician, nurse, and patient problem lists for Pneumocystis pneumonia patients show overlap in medical issues but unique insights in nursing and patient-generated lists, highlighting the need for a unified approach.

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Area of Science:

  • Medical Informatics
  • Nursing Research
  • Patient-Reported Outcomes

Background:

  • Problem lists are crucial for patient care documentation.
  • Discrepancies in problem lists can lead to fragmented care.
  • Understanding the overlap and unique contributions of different sources is vital.

Purpose of the Study:

  • To compare problem lists generated by physicians, nurses, and patients for Pneumocystis carinii pneumonia (PCP) patients.
  • To identify areas of overlap and unique problems within each list.
  • To advocate for a unified problem list for improved patient care and electronic health records.

Main Methods:

  • Analysis of problem lists from 201 hospitalized PCP patients.
  • Comparison of physician-generated lists with nurse- and patient-generated lists.

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  • Identification of common and unique problems across all three sources.
  • Main Results:

    • Significant overlap exists for problems related to the primary medical diagnosis and symptoms.
    • Nurse lists uniquely identified knowledge deficits and potential for injury.
    • Patient lists revealed psychosocial problems not captured by clinicians (34%).

    Conclusions:

    • Nurse and patient problem lists offer critical, unique data impacting patient status and outcomes.
    • A unified, multidisciplinary problem list is essential for comprehensive patient views.
    • Development of data models and controlled vocabularies is needed for integrated electronic patient record systems.