协作文档对行为健康环境中临床笔记的完整性和长度的影响
Nari Yoo1, Elizabeth Matthews1, Daniel Baslock1
1Silver School of Social Work, New York University, New York City (Yoo, Baslock, Stanhope); Graduate School of Social Service, Fordham University, New York City (Matthews).
Psychiatric services (Washington, D.C.)
|August 2, 2023
概括
社区心理健康诊所的协作文档在大多数临床笔记部分增加了信息. 然而,在这种联合文档实践实施后,客户感受部分不太可能包含内容.
科学领域:
- 临床信息学 临床信息学
- 心理健康服务研究 心理健康服务研究
背景情况:
- 在社区心理健康中,越来越多地采用了临床医生和消费者共同记录遭遇的协作文档.
- 对这种做法对临床文档的影响的研究是有限的.
研究的目的:
- 为了调查社区心理健康访问笔记的结构和内容的变化,在协作文档的实施后.
主要方法:
- 通过临床信息学方法,分析了来自9家医疗服务提供商的1,875份访客笔记.
- 固定效应回归模型比较了实施前和后的笔记,控制治疗师效应.
主要成果:
- 在协作文档实施后,观察到参观笔记结构的显著变化.
- 在10个注释部分中,有6个显示信息增加 (单词/字符数量).
- 详细介绍客户感受的部分含有内容的可能性明显低 (OR=0.01,p<0.001).
结论:
- 协作文档显著影响社区心理健康环境中的临床笔记的内容和结构.
- 虽然整体笔记细节增加了,但客户感受的记录可能会减少.
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