与在临床笔记中讨论高血压读数相关的因素
Cole G Chapman1, Philip M Polgreen2, Manish Suneja2
1Department of Pharmacy Practice and Science, University of Iowa, Iowa City, Iowa, USA.
American journal of hypertension
|December 11, 2024
概括
高血压 (HBP) 通常不会在临床笔记中讨论,即使是在初级保健中. 增加HBP的文档可能有助于预防高血压的诊断延迟.
科学领域:
- 临床医学 临床医学
- 医疗信息学 医疗信息学
- 心血管健康 心血管健康
背景情况:
- 血压 (BP) 在医疗保健访问期间经常测量.
- 高血压 (HBP) 的测量经常没有记录在临床笔记中.
- 了解影响HBP讨论的因素对于患者护理至关重要.
研究的目的:
- 确定与临床笔记中高血压 (HBP) 测量的讨论相关的患者和访问级因素.
- 分析没有先前高血压诊断的患者中HBP的文档实践.
主要方法:
- 在2016年至2022年期间,利用电子医疗记录来记录患有高于140/90mmHg血压的患者的血压.
- 排除了任何先前高血压诊断的患者.
- 采用多级回归模型来评估在临床笔记中影响HBP讨论的因素.
主要成果:
- 在278,766次门诊访问中,有61,739例患有HBP;只有31%在笔记中讨论.
- 即使在初级保健中,HBP也只在70%的相关访问中讨论.
- 发烧,外部损伤/疼痛和多种并发症降低了HBP讨论几率;之前的HBP讨论增加了几率.
结论:
- 在临床笔记中对高血压 (HBP) 的讨论显著不足.
- 改善HBP的文档可以减轻诊断惯性,改善高血压管理.
- 可能需要针对性的干预措施,以确保在临床笔记中对HBP进行一致的讨论.
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