系统形式的审查中传递的信息的感知:定性描述
Natalie C Ernecoff1, Jonathan Arnold2,3, Tamar Krishnamurti2
1RAND Corporation, Pittsburgh, PA, USA.
Journal of general internal medicine
|February 20, 2025
概括
系统审查 (ROS) 形式显示临床医生和公众之间存在广泛的术语差异和误解. 这种不一致性影响了患者护理和电子健康记录 (EHR) 文档.
科学领域:
- 医疗信息学 医疗信息学
- 临床评估工具 临床评估工具
- 卫生沟通健康沟通
背景情况:
- 系统审查 (ROS) 形式是标准的临床评估和计费工具.
- 在ROS术语及其解释中存在显著的变化.
- 了解这些变化对于患者护理和电子健康记录 (EHR) 的实施至关重要.
研究的目的:
- 建立一个代表性的 ROS 术语列表.
- 评估临床医生和非专业志愿者对ROS术语的定义和误解的范围.
主要方法:
- 对现有的ROS表格进行定性审查.
- 使用心理模型框架进行定性采访,与临床医生和非专业志愿者进行采访.
- 专家临床医生为ROS术语制定共识定义.
主要成果:
- 临床医生在一般操作定义上达成共识,但在症状时间框架,持续时间和细微差别方面表现出常见的误解.
- 非专业的志愿者对ROS术语有不同的解释,往往与临床医生的理解不同.
- 观察到不一致的操作化和ROS术语的定义.
结论:
- 在临床医生和公众中,对ROS术语的误解普遍存在.
- ROS表格有助于增加患者,家庭和护理人员的负担.
- 使用更广泛的术语和直接的患者讨论可能更好地满足计费和患者需求.
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