患者报告的症状与外科医生诊所外科医生诊所期间的肺部病理学文档相比:一项回顾性患者报告的结果测量研究
Kendra E Wulczyn1, Annie Liu1, James P Lash2
1Nephrology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
Kidney medicine
|June 13, 2025
概括
科医生在电子健康记录中对患者症状的记录是不准确的,敏感度低. 这强调了需要更好的工具来跟踪慢性病 (CKD) 患者的症状负担.
科学领域:
- 腎臟病學 (nephrology) 是一種醫學專業.
- 医疗信息学 医疗信息学
- 患者报告的结果
背景情况:
- 慢性病 (CKD) 的有效管理依赖于对患者症状负担的公开沟通.
- 在常规脏病诊所中,症状的讨论和记录程度尚不清楚.
研究的目的:
- 为了比较患者报告的CKD症状与科医生在电子健康记录 (EHR) 中的文档.
- 评估在门诊脏病诊所遇到的症状记录的准确性.
主要方法:
- 对患者报告的结果指标 (病生命质量简短表格 - KDQOL-SF) 和EHR文档的回顾性分析.
- 用自然语言处理和手动审查来识别临床笔记中的症状.
- 用患者报告作为参考标准计算了文档的敏感性和特异性.
主要成果:
- 对于患者报告的症状,科医生文档的平均敏感度低至16%,特异性为98%.
- 根据患者人口统计 (女性,较低的eGFR,心血管疾病史) 和科医生特征 (女性,职业生涯早期) 的基础上,文档敏感性有所不同.
- 对于所有评估的症状,个体症状记录的敏感度低于40%.
结论:
- 在EHR中,科医生对CKD相关症状的记录显著低于患者报告的症状.
- 这种差异表明,在临床接触期间捕捉患者症状负担方面存在关键差距.
- 显然需要改进工具和标准化流程,以提高CKD护理中的症状评估和文档.
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