在入院时患者与临床医生的诊断一致性
Alyssa Lam1, Savanna Plombon1, Alison Garber1
1Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States.
Applied clinical informatics
|September 18, 2024
概括
大约一半的患者诊断与临床医生的输入相匹配. 患者的信心和未指定的ICD-10"R代码"预测了医院住院早期的诊断差异.
科学领域:
- 医疗信息学 医疗信息学
- 患者报告的结果
- 临床诊断 临床诊断 临床诊断
背景情况:
- 准确的患者诊断对于有效的治疗至关重要.
- 患者对诊断的理解会影响医疗保健的结果.
- 评估患者和临床医生的诊断认知之间的一致性至关重要.
研究的目的:
- 为基于应用程序使用的患者诊断问卷 (PDQ) 进行试点.
- 评估患者报告和临床医生输入的入院诊断之间的一致性.
- 为了确定预测诊断非一致的因素.
主要方法:
- 进行PDQ以评估患者对诊断的理解和信心.
- 从电子健康记录 (EHR) 中检索入院诊断和ICD-10代码.
- 医生评价一致性;多变量逻辑回归分析了非一致性的预测因素.
主要成果:
- 填写了157份问卷,49%的诊断结果完全一致.
- 患者报告的缺乏信心与非一致性有关.
- 使用ICD-10"R-代码"主要问题预测的非一致性.
结论:
- 大约50%的患者报告的诊断与临床医生的条目一致.
- 患者的信心和未指定的ICD-10"R码"是诊断不一致的早期预测因素.
- 该PDQ显示了确定潜在的患者和临床医生的诊断差距的前景.
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