Chisholm Carey D, Weaver Christopher S, Whenmouth Laura F, Giles Beverly, Brizendine Edward J
Department of Emergency Medicine, Division of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA.
Ann Emerg Med. 2008 Oct;52(4):383-9. doi: 10.1016/j.annemergmed.2008.01.004. Epub 2008 Mar 14.
The Joint Commission requires "appropriate assessment" of patients presenting with painful conditions. Compliance is usually assessed through retrospective chart analysis. We investigate the discrepancy between observed physician pain assessment and that subsequently documented in the medical record.
This was an observational study using a trained investigator watching bedside interactions of emergency physicians. Using a priori definitions, the investigator recorded whether the patient volunteered the presence of pain, physician inquiry about pain, attempts to quantify the pain, treatment offered/rendered, and any assessment of the response to therapy. An independent investigator subsequently assessed the patient's chart for documentation of pain assessment, therapy rendered, and response to treatment. Children younger than 5 years and patients with major trauma, altered mental status, or nontraumatic chest pain were excluded. The institutional review board approved the protocol, the physicians agreed to participate in an "ergonomic study" without knowing the exact nature of data collection, and patients released their records.
The investigator observed 209 patient encounters. Physicians acknowledged the patients' pain 98.1% of the time but documented its presence in 91.7%. Physicians attempted to quantify the patient's pain in 61.5% of encounters but documented that attempt in only 38.9%. Treatment was offered in 79.9% and recorded in 31.7% of charts. When treatment was offered, the patient's response to the therapy was recorded only 28% of the time.
Physicians almost always assess and treat patient pain but infrequently record those efforts. The patient's chart is a poor surrogate marker for pain assessment and care by emergency physicians and may not be suitable for use as a compliance assessment tool. Research methodology using retrospective chart analysis may be affected by this phenomenon, suggesting the potential for underestimation of patient pain assessment and treatment by emergency physicians.
联合委员会要求对出现疼痛症状的患者进行“适当评估”。通常通过回顾性病历分析来评估是否合规。我们调查了观察到的医生疼痛评估与随后病历记录之间的差异。
这是一项观察性研究，由一名经过培训的调查员观察急诊医生的床边诊疗互动。根据预先设定的定义，调查员记录患者是否主动提及疼痛、医生是否询问疼痛、是否尝试对疼痛进行量化、提供/实施的治疗，以及对治疗反应的任何评估。随后，另一名独立调查员评估患者病历，以查看疼痛评估、实施的治疗以及治疗反应的记录情况。排除5岁以下儿童以及有严重创伤、精神状态改变或非创伤性胸痛的患者。机构审查委员会批准了该方案，医生们同意参与一项“人体工程学研究”，但并不知晓数据收集的确切性质，患者也同意公开其病历。
调查员观察了209例患者诊疗过程。医生在98.1%的情况下承认患者疼痛，但病历记录中提及疼痛的比例为91.7%。医生在61.5%的诊疗过程中尝试对患者疼痛进行量化，但只有38.9%的情况记录在病历中。79.9%的情况下提供了治疗，但只有31.7%记录在病历中。当提供治疗时，仅28%的情况记录了患者对治疗的反应。
医生几乎总是对患者疼痛进行评估和治疗，但很少记录这些工作。患者病历对于急诊医生的疼痛评估和护理而言是一个较差的替代指标，可能不适用于作为合规评估工具。使用回顾性病历分析的研究方法可能会受到这种现象的影响，这表明急诊医生对患者疼痛评估和治疗的情况可能被低估。
