在医院医学中遇到与阿片类药物相关的诊断代码之间存在耻辱性文档的发生:队列研究
William S Bradford1, Reed W R Bratches2, Hollie Porras3
1Division of Infectious Diseases, University of Alabama Birmingham, Birmingham, AL, United States.
医生在阿片类药物使用障碍文档中使用污名化语言是常见的. 无家可归和多种物质的使用被独立地与这种偏见的语言联系在一起.
科学领域:
- 医疗文件 医疗文件
- 临床语言学 临床语言学
- 公共卫生 公共卫生
背景情况:
- 医生在治疗阿片类药物使用障碍 (OUD) 的住院患者的临床笔记中使用污名化语言很普遍.
- 与OUD文档中这种污名化语言相关的患者因素尚未得到充分理解.
研究的目的:
- 调查与医生在阿片类药物相关诊断患者的文档中使用污名化语言相关的人口统计因素和临床结果.
- 为了确定与临床记录中的偏见语言相关的特定患者特征.
主要方法:
- 分析2020年医院遇到与阿片类药物有关的ICD-10代码的情况.
- 审查病史和身体和释放摘要的耻辱化语言.
- 多变量逻辑回归用于评估患者因素与耻辱化语言之间的关联.
主要成果:
- 在29%的经过分析的遭遇中,存在污名化的语言.
- 术语"滥用药物"经常被使用,而不是"使用药物".
- 多种物质的使用 (aOR 7.83) 和无家可归 (aOR 2.44) 独立地与污名化的语言有关.
结论:
- 在OUD住院患者的医生文档中,污名化语言是常见的.
- 在这些临床笔记中,并发性多种物质使用和无家可归是污名化语言的重要独立预测因素.
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Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
Methods of Documentation I: Source-Oriented Records
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:
Guidelines for Nursing Documentation II
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
Methods of Documentation II: POMR
