初级临床医生诊断确定性水平:一项回顾性队列研究。

Yang Chen, Myura Nagendran, Yakup Kilic, Dominic Cavlan, Adam Feather, Mark Westwood, Edward Rowland, Charles Gutteridge, Pier D Lambiase
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引用次数: 1

摘要

背景:临床决策受到许多因素的影响,包括临床医生对最佳行动方案的确定性的看法。目的:表征工作诊断的文件和临床医生表达的实时确定性的相关水平,并衡量患者对临床医生决策确定性研究的重要性的意见。方法:这是一项单中心回顾性队列研究,纳入了2019年3月1日至2019年3月31日期间从急诊科入院的非会诊级临床医生及其评估。提取去识别的电子健康记录形式,包括记录的诊断类型和使用的确定性形容词。病人的意见是从焦点小组中征求的。结果:在研究期间,分析了850份办事员表格;420例为单一诊断,430例为多重诊断。在420例单一诊断中,67例(16%)被记录为症状或体征,16例(4%)是实验室结果定义的诊断。309例(74%)的诊断没有不确定性。在430例多重诊断中,有346例(80%)不确定,而没有不确定的84例(20%)不确定。病人焦点小组一致支持这项研究。结论:非会诊级临床医生的工作诊断文件差异很大。在近四分之三的单一诊断评估中,没有不确定性因素被暗示或量化。多重诊断的不确定性大于单一诊断。意义:文件标准化的提高将有助于未来的研究更好地分析和量化单一和多个工作诊断的诊断确定性。这可能导致后续检查它们与重要过程或临床结果测量的关联。
本文章由计算机程序翻译,如有差异,请以英文原文为准。

The diagnostic certainty levels of junior clinicians: A retrospective cohort study.

The diagnostic certainty levels of junior clinicians: A retrospective cohort study.

The diagnostic certainty levels of junior clinicians: A retrospective cohort study.

The diagnostic certainty levels of junior clinicians: A retrospective cohort study.

Background: Clinical decision-making is influenced by many factors, including clinicians' perceptions of the certainty around what is the best course of action to pursue.

Objective: To characterise the documentation of working diagnoses and the associated level of real-time certainty expressed by clinicians and to gauge patient opinion about the importance of research into clinician decision certainty.

Method: This was a single-centre retrospective cohort study of non-consultant grade clinicians and their assessments of patients admitted from the emergency department between 01 March 2019 and 31 March 2019. De-identified electronic health record proformas were extracted that included the type of diagnosis documented and the certainty adjective used. Patient opinion was canvassed from a focus group.

Results: During the study period, 850 clerking proformas were analysed; 420 presented a single diagnosis, while 430 presented multiple diagnoses. Of the 420 single diagnoses, 67 (16%) were documented as either a symptom or physical sign and 16 (4%) were laboratory-result-defined diagnoses. No uncertainty was expressed in 309 (74%) of the diagnoses. Of 430 multiple diagnoses, uncertainty was expressed in 346 (80%) compared to 84 (20%) in which no uncertainty was expressed. The patient focus group were unanimous in their support of this research.

Conclusion: The documentation of working diagnoses is highly variable among non-consultant grade clinicians. In nearly three quarters of assessments with single diagnoses, no element of uncertainty was implied or quantified. More uncertainty was expressed in multiple diagnoses than single diagnoses.

Implications: Increased standardisation of documentation will help future studies to better analyse and quantify diagnostic certainty in both single and multiple working diagnoses. This could lead to subsequent examination of their association with important process or clinical outcome measures.

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