Cockayne Nicole L, Duguid Margaret, Shenfield Gillian M
Royal North Shore Hospital, Clinical Pharmacology, St Leonards, NSW, Australia.
Br J Clin Pharmacol. 2005 Feb;59(2):254-8. doi: 10.1111/j.1365-2125.2004.02328.x.
AIMS: To identify the completeness of documentation of Complementary And Alternative Medicine (CAM) use in hospital medical records of patients before and after an education programme. METHODS: Documentation of CAM in all parts of the medical records was compared to patients' self-reported use. Data were collected for one month before and one month after an education programme for hospital staff. RESULTS: At baseline: 59 (58%) of 101 patients used 129 CAM in the month prior to admission; only 36 (28%) of the CAM were documented in the medical record. After education: 51 (54%) of 94 patients used 91 CAM in the month prior to admission; 40 (44%) of the CAM were documented in the medical record. After education, recording rates increased by 16% (95% CI: 3% to 29%) due to improvements by pharmacists (18%, 95% CI: 5% to 31%). 32 (54%) of CAM users at baseline and 29 (57%) of CAM users after education informed a health professional. The recording rates were only 23 (39%) and 28 (55%) respectively for patients in these two sub-groups, being an improvement of 16% (95% CI: -2% to 34%). CONCLUSIONS: Prevalence of CAM use among patients admitted to hospital is high, but documentation of usage is low. Strategies need to be designed to improve health professionals' knowledge about the need to record history of CAM use.
目的:确定在一项教育计划前后,患者医院病历中补充和替代医学(CAM)使用情况的记录完整性。 方法:将病历所有部分中CAM的记录情况与患者自我报告的使用情况进行比较。在针对医院工作人员的一项教育计划开展前一个月和开展后一个月收集数据。 结果:基线时:101例患者中有59例(58%)在入院前一个月使用了129种CAM;病历中仅记录了36种(28%)CAM。教育后:94例患者中有51例(54%)在入院前一个月使用了91种CAM;病历中记录了40种(44%)CAM。教育后,由于药剂师记录情况的改善,记录率提高了16%(95%置信区间:3%至29%)。基线时32例(54%)CAM使用者和教育后29例(57%)CAM使用者告知了医疗专业人员。这两个亚组患者的记录率分别仅为23例(39%)和28例(55%),提高了16%(95%置信区间:-2%至34%)。 结论:入院患者中CAM的使用率很高,但使用情况的记录率很低。需要设计策略来提高医疗专业人员对记录CAM使用史必要性的认识。
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