挪威创伤登记数据与电子病历中的相应数据相比,非常一致
N Naberezhneva1, Oddvar Uleberg2,3, M Dahlhaug4
1Biobank and Registry Support Department, Division for medical quality registries for South- Eastern Norway Regional Health Authority, Oslo University Hospital, Oslo, Norway.
Scandinavian journal of trauma, resuscitation and emergency medicine
|September 26, 2023
概括
挪威创伤登记处 (NTR) 的数据质量很高,显示出登记处数据和电子病历 (EPR) 之间的良好一致性. 建议进一步检查特定变量中缺少的数据,以提高创伤护理质量.
科学领域:
- 医疗信息学 医疗信息学
- 医疗保健服务研究 医疗服务研究
- 创伤护理质量的提高 创伤护理质量的提高
背景情况:
- 挪威创伤登记处 (NTR) 收集数据,以监测和提高创伤护理质量.
- 高质量的注册数据对于创伤护理评估的有效性和实用性至关重要.
- 本研究通过将NTR数据与电子病历 (EPR) 进行比较来评估数据质量.
研究的目的:
- 在挪威创伤登记处对核心数据元素进行数据质量检查.
- 评估NTR中的数据与EPR中的相应数据之间的一致性.
- 确保用于创伤护理评估的数据的可靠性和可信性.
主要方法:
- 在2019年入院的180名创伤患者中,从NTR与EPR中验证了49个变量.
- 采用了包括科恩的卡帕,Gwet的协议系数 (AC1,AC2) 和类内相关系数 (ICC) 在内的统计措施.
- 分析了名义,顺序,连续,日期和时间变量的协议.
主要成果:
- 在所有验证变量中观察到几乎完美的一致性 (AC1/AC2/ICC>0.80).
- 对于名义和顺序变量,Gwet的协议系数在0.85到1.00之间.
- 连续和时间变量的类内相关系数很高,从0.88到1.00不等.
- 总的来说,发现了可以忽略不计的缺失值,除了"基数过剩"和一些时间变量.
结论:
- 挪威创伤注册表显示,数据与电子病历有很好的数据一致性.
- 在NTR中核心数据元素的质量是强大的和可靠的临床使用.
- 需要对缺少数据的特定变量进行进一步调查,以优化注册表.
相关概念视频
01:30Methods of Documentation VII: EMR
855
Electronic Medical Records (EMRs) primarily center around electronically documenting patients' health information within a single healthcare organization or practice. They contain essential clinical data related to a patient's medical history, diagnoses, medications, treatment plans, lab results, and other pertinent information relevant to the specific encounter or episode of care. EMRs are designed to streamline documentation and workflow processes within individual healthcare...
855
01:24Data Reporting and Recording
4.7K
Reporting and recording are crucial in data documentation. The timely, thorough, and accurate documentation of facts is essential when recording patient data. Failure to record findings during an assessment or interpretation of a problem will result in loss of information and make the patient document unreliable. The reader is left with general impressions if the information is not specific. A recording is documenting data of the individual's health information in a traceable, secure, and...
4.7K
01:26Methods of Documentation II: POMR
982
The Problem-Oriented Medical Record (POMR) revolutionized medical record-keeping by introducing a systematic approach focusing on the patient's problems rather than merely listing symptoms. Dr. Lawrence Weed's introduction of this method in the 1960s marked a significant advancement in medical documentation. The POMR framework consists of four key components: the database, problem list, plan of care, and progress notes.
982
01:19Purpose of Health Records II
985
Health records serve various essential purposes in the healthcare system. Here are some key purposes:
985
01:11Purpose of Health Records I
1.2K
The vital purpose of health records is to provide a complete and accurate account of a patient's medical history, including communication, diagnostic and therapeutic orders, care planning, research, and quality review.
Here's a breakdown of how health records serve these purposes:
Here's a breakdown of how health records serve these purposes:
1.2K
01:27Types of Records I: Unit and Nurses Records
1.1K
Unit records in healthcare settings document the patient's treatment history, including interventions, medications, diagnostic and laboratory results, progress notes, personal care needs, vital signs, and other medical information. They are crucial for managing patient care, aiding healthcare professionals in providing quality treatment and informed decision-making.
Unit records can be divided into two main types: administrative records and clinical records.
Administrative records in...
Unit records can be divided into two main types: administrative records and clinical records.
Administrative records in...
1.1K