不明确的轨迹和不确定的好处:创建一个词典临床不确定性在患有严重或晚期疾病的患者使用德尔菲共识过程
Samuel K McGowan1, Maria-Jose Corrales-Martinez2, Teva Brender3
1Department of Internal Medicine, Division of Pulmonary and Critical Care, University of California, San Francisco, San Francisco, CA, USA.
概括
医生经常使用44个特定的单词和短语来记录重症监护室 (ICU) 的临床不确定性. 这个词典有助于从电子健康记录中提取有价值的数据,反映了严重疾病的复杂性.
科学领域:
- 医疗信息学 医疗信息学
- 临床交流 临床沟通
- 改善医疗保健质量 改善医疗保健质量
背景情况:
- 临床不确定性使重症监护复杂化,影响患者的生活质量并增加医疗保健成本.
- 目前在临床笔记中识别不确定性的方法是手动的,耗时的.
- 开发可扩展的方法来提取不确定性数据对于改善护理至关重要.
研究的目的:
- 制定医生用来描述临床不确定性的术语共识清单.
- 了解医生如何记录重症监护室 (ICU) 的不确定性.
- 为了促进从医疗记录中大规模提取不确定性数据.
主要方法:
- 进行了德尔菲共识研究,涉及全国各地的医生.
- 参与者在五轮中确定并完善了代表临床不确定性的单词列表.
- 对开放式调查答案的专题分析探索了这些术语在文档中的使用.
主要成果:
- 在44个表明临床不确定性的单词或短语上达成共识.
- 医生报告说,在电子健康记录中使用这些术语感到舒适.
- 记录的不确定性用于详细说明诊断过程,寻求帮助和确认不完整信息等目的.
结论:
- 通过共识过程成功创建了一个不确定性词典.
- 医生很容易记录在重症监护机构的不确定性.
- 这个词典使得有效的数据提取,提供了深刻的了解到危急疾病文档的复杂性.
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