针对有效,可持续和可扩展的治疗特征方法:从图表注释中对临床实践编码的调查
Benjamin M Isenberg1, Kimberly D Becker2, Eleanor Wu2
1Department of Psychology, University of California Los Angeles, Franz Hall, Los Angeles, CA, 90095, United States of America.
Administration and policy in mental health
|November 30, 2023
概括
图表注释提供了一种评估治疗细节的实用方法,显示实践和步骤的适度可靠性. 虽然它们与转录的会议不完全匹配,但它们为改善护理管理提供了有价值,可访问的数据.
科学领域:
- 临床信息学是一种临床信息学.
- 医疗服务研究 医疗服务研究
- 心理治疗的研究研究.
背景情况:
- 临床文档,如图表注释,是一个易于获得和低成本的数据来源.
- 准确地描述治疗内容对于改善患者护理管理至关重要.
- 评估从图表注释中提取的数据的可靠性和有效性对于其有效使用至关重要.
研究的目的:
- 为了评估从临床图表注释中编码的治疗内容的interrater可靠性.
- 评估从图表笔记中编码的治疗内容与转录的治疗会话之间的一致性.
主要方法:
- 50个随机选择的治疗事件被转录并编码为实践内容.
- 独立的编码者使用相同的编码系统来绘制相同处理事件的图表注释.
- 可靠性和一致性是在实践 (完整程序) 和步骤 (子组件) 的水平上测量.
主要成果:
- 图表注释显示了实践中适度的评分器间可靠性 (kappa=.50,ICC=.56) 和步骤中适度至实质性可靠性 (ICC=.74,kappa=.78).
- 在64%的实践和41%的步骤中,发现图表注释和成绩单之间存在显著的相关性,相对应程度适度.
- 41%的实践和34%的成绩单步骤可以在相应的图表注释中识别.
结论:
- 图表注释可以作为评估治疗内容的可访问数据源.
- 图表注释中的编码的特殊性会影响其有效性和可靠性,影响测量的潜在改进.
- 这些发现对设计图表笔记接口,培训和开发临床实践测量的新指标有影响.
相关概念视频
01:15Methods of Documentation VI: Case Management Model
574
The case management model is a multidisciplinary approach that involves healthcare professionals from diverse disciplines, such as physicians, nurses, therapists, social workers, and pharmacists, working collaboratively to address the various needs of patients. Each healthcare professional brings unique expertise and perspectives, contributing to a more comprehensive understanding of the patient's condition and tailoring treatment plans accordingly.
For example, a patient with a chronic...
For example, a patient with a chronic...
574
01:26Methods of Documentation IV: Focus Charting
1.0K
Focus Charting, also known as the focus charting system or "focus documentation," is a systematic documentation approach used in healthcare to organize patient information in medical records.
It typically involves three columns for recording information:
It typically involves three columns for recording information:
1.0K
01:23Methods of Documentation V: CBE
906
Charting by Exception, or CBE, is a method of documentation used in healthcare, particularly in nursing, that focuses on documenting only significant or abnormal findings rather than recording every detail. This approach aims to streamline the documentation process, improve efficiency, and ensure that healthcare providers can quickly identify deviations from normalcy in patient assessments.
In CBE, healthcare professionals establish predefined standards of practice that define what constitutes...
In CBE, healthcare professionals establish predefined standards of practice that define what constitutes...
906
01:18Methods of Documentation I: Source-Oriented Records
1.1K
Source-oriented records, or SOR, are medical record-keeping organized by the data source. The SOR system was first developed in the mid-1900s to organize the growing patient data in hospitals and other healthcare facilities.
In an SOR, each discipline involved in patient care maintains a separate medical record section. This record-keeping method enables easy tracking of patient progress and ensures healthcare staff have access to up-to-date information.
Key Attributes include the following:
In an SOR, each discipline involved in patient care maintains a separate medical record section. This record-keeping method enables easy tracking of patient progress and ensures healthcare staff have access to up-to-date information.
Key Attributes include the following:
1.1K
01:26Methods of Documentation II: POMR
959
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.
959
01:17Flow Sheet
1.6K
Flowsheets are valuable tools in nursing documentation. They enable healthcare professionals to efficiently record and monitor various patient assessments and measurements in a consolidated format.
Here's a closer look at the examples of flowsheets commonly used by nurses:
Graphic Sheet Documentation:
Here's a closer look at the examples of flowsheets commonly used by nurses:
Graphic Sheet Documentation:
1.6K