吞的灵活内镜评估中的变异性 文档模板:一个横截面数据库研究
Nihal Punjabi1,2, Nicholas J Ogrinc1,2, Alexis Nahra2
1School of Medicine, Case Western Reserve University, Cleveland, OH.
American journal of speech-language pathology
|March 12, 2026
概括
用于灵活内镜评估吞 (FEES) 的文档在使用共同的EHR的医疗机构之间有很大差异. 标准化FEES报告对于改善食障碍管理和实现协作研究至关重要.
科学领域:
- 医疗信息学 医疗信息学
- 语音语言病理学 语言病理学
- 胃肠病学 胃肠病学
背景情况:
- 电子健康记录 (EHR) 在医疗保健中越来越多地使用,但记录实践可能有很大差异.
- 吞的灵活内镜评估 (FEES) 是吞障碍的关键诊断工具,需要一致的文档才能有效地照顾患者.
- FEES文件的变化可能会阻碍机构间的合作和研究.
研究的目的:
- 描述多个医疗机构在电子健康记录 (EHR) 系统中的吞 (FEES) 文档灵活内镜评估的变异性.
- 评估标准化组件和评级尺度在多大程度上被纳入FEES文档模板.
主要方法:
- 在Epic社区图书馆的搜索中,发现了来自475个机构的243个独特的成人住院费用模板.
- 模板与基于FEES综合指南的16个组件检查清单进行了评估.
- 评估了包括分泌物,残留物和透吸收标准化尺度的情况.
主要成果:
- 试验一致性,喉阶段评估和透-吸收评估是最频繁记录的组成部分.
- 染料颜色,感官测试和下喉反流是最少经常记录的.
- 穿透吸收,分泌和残留的标准化尺度分别用于46.5%,24.3%和19.3%的模板.
结论:
- 在使用共享EHR平台的机构之间,FEES文档存在显著的变化.
- 需要在FEES报告中促进标准化,以加强食障碍的评估,管理和多机构研究.
- 标准化的FEES文档可以促进临床合作,并改善吞障碍患者的护理.
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