一项关于心血管疾病患者生活习惯的回顾性队列研究：病历资料的信息量有多大？
A retrospective cohort study on lifestyle habits of cardiovascular patients: how informative are medical records?
作者信息
Fouwels Annemarie J, Bredie Sebastiaan J H, Wollersheim Hub, Schippers Gerard M
机构信息
Amsterdam Institute for Addiction Research, AMC, Meibergdreef 5, 1105 AZ, Amsterdam, the Netherlands.
出版信息
BMC Health Serv Res. 2009 Apr 1;9:59. doi: 10.1186/1472-6963-9-59.
BACKGROUND
To evaluate the vigilance of medical specialists as to the lifestyle of their cardiovascular outpatients by comparing lifestyle screening as registered in medical records versus a lifestyle questionnaire (LSQ), a study was carried out at the cardiovascular outpatient clinic of the university hospital of Nijmegen, The Netherlands, between June 2004 and June 2005.
METHODS
For 209 patients information from medical records on lifestyle habits, physician feedback, and interventions in the past year was compared to data gathered in the last month by a self-report LSQ.
RESULTS
Doctors register smoking habits most consistently (90.4%), followed by alcohol use (81.8%), physical activity (50.2%), and eating habits (27.3%). Compared to the LSQ, smoking, unhealthy alcohol use, physical activity, and unhealthy eating habits are underreported in medical records by 31, 83, 54 and 97%, respectively. Feedback, advice or referral was documented in 8% for smoking, 3% for alcohol use, 12% for physical activity, and 26% for eating habits.
CONCLUSION
Lifestyle is insufficiently registered or recognized by doctors providing routine care in a cardiovascular outpatient setting. Of the unhealthy lifestyle habits that are registered, few are accompanied by notes on advice or intervention. A lifestyle questionnaire facilitates screening and interventions in target patients and should therefore be incorporated in the cardiovascular setting as a routine patient intake procedure.
背景
为了通过比较病历中记录的生活方式筛查与生活方式问卷（LSQ）来评估医学专家对心血管门诊患者生活方式的关注度，2004年6月至2005年6月在荷兰奈梅亨大学医院的心血管门诊进行了一项研究。
方法
将209名患者过去一年病历中关于生活习惯、医生反馈和干预措施的信息与上个月通过自我报告LSQ收集的数据进行比较。
结果
医生对吸烟习惯的记录最为一致（90.4%），其次是饮酒情况（81.8%）、体育活动（50.2%）和饮食习惯（27.3%）。与LSQ相比，病历中吸烟、不健康饮酒、体育活动和不健康饮食习惯的报告分别少了31%、83%、54%和97%。记录了吸烟方面反馈、建议或转诊的占8%，饮酒方面占3%，体育活动方面占12%，饮食习惯方面占26%。
结论
在心血管门诊提供常规护理的医生对生活方式的记录或认知不足。在记录的不健康生活习惯中，很少有伴随建议或干预的记录。生活方式问卷有助于对目标患者进行筛查和干预，因此应作为常规患者接诊程序纳入心血管诊疗环境中。
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