验证重症监护室病房转移笔记的医生文档质量仪器.
Patrick G Lyons1,2, Juan C Rojas3, Alice F Bewley4
1Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, and.
ATS scholar
|July 26, 2024
概括
修改后的医生文档质量仪器 (mPDQI-9) 显示了评估重症监护室 (ICU) 到普通病房患者转移笔记的质量适度有效性. 这个工具有助于改善医生在患者交接期间的沟通.
科学领域:
- 医疗信息学 医疗信息学
- 改善医疗保健质量 改善医疗保健质量
- 临床交流 临床沟通
背景情况:
- 在将患者从重症监护室 (ICU) 转移到普通病房期间,医生沟通失败是常见的,并可能导致不良事件.
- 改进书面转移笔记至关重要,但目前还没有标准化的工具来评估这些医生转移笔记的质量.
研究的目的:
- 为了收集修改后的九项医生文档质量仪器 (mPDQI-9) 的有效性证据.
- 在多个医院设置中评估ICU-to-ward转移笔记的有用性.
主要方法:
- 24名医生评价员使用mPDQI-9.9评估了来自三个学术医院的12份转移笔记.
- 评估的具体领域包括彻底性,有用性,组织性,可理解性,简洁性,综合性和一致性.
- 标准有效性 (斯皮尔曼的 ρ) 和评价者之间的可靠性 (类内相关性 [ICC]) 是主要的措施.
主要成果:
- 平均mPDQI-9分数因注意事项而异,感知到的临床效用显示出中等的正相关性 (ρ=0.48).
- 评分器间可靠性很强 (ICC=0.89),内部一致性很好 (克朗巴赫的α=0.87).
- 根据评级人员的专业知识,注意评级并没有显著差异.
结论:
- mPDQI-9为评估ICU-to-ward转移笔记的有用性提供了适度的有效性证据.
- 这种工具可以帮助评估和提高医生在关键患者过渡期间的医生文档质量.
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