San Francisco General Hospital, San Francisco, California, USA.
Am J Gastroenterol. 2010 Mar;105(3):484-9. doi: 10.1038/ajg.2009.686.
To assess the completeness of gastrointestinal (GI) inpatient consultations at an academic teaching hospital.
We conducted a prospective, cross-sectional study of 278 inpatient GI consultation requests evaluated from 1 July 2005 to 31 May 2007. A questionnaire assessing multiple aspects of the requesting health-care providers' knowledge and documentation of patient information was completed by first-year GI fellows. Completeness of the consultation was evaluated by the GI consultation attending physician.
The most frequent consultation requests pertained to patients with GI hemorrhage (52.5%) and were made by first-year residents (56.8%). In 15% of requests, health-care providers lacked basic knowledge about the patients for whom consultations were sought. Conversely, in 17% of consultations, pertinent information could not be located in patients' paper medical chart/electronic medical record. The strongest predictors for a complete consultation were requesters' knowledge of patients' past medical history (P < 0.001), documentation of patients' current illness (P < 0.001), and presence of the providers' admission note in the paper medical chart (P = 0.002). Consultations requested between 5 and 10 PM were assessed to be more complete (P = 0.02), and more incomplete consultations occurred in the first 3 months of the academic year (P = 0.04).
In 16% of inpatient GI consultation requests analyzed, crucial patient data were missing or were unknown by the requesting provider. Several aspects of requesting providers' knowledge and documentation of patient information were strongly associated with completeness of inpatient GI consultations.
评估一家学术教学医院的胃肠道（GI）住院会诊的完整性。
我们对 2005 年 7 月 1 日至 2007 年 5 月 31 日评估的 278 份 GI 会诊请求进行了前瞻性、横断面研究。第一年 GI 研究员完成了一份评估请求者对患者信息的知识和记录的多个方面的问卷。GI 会诊主治医生评估了会诊的完整性。
最常见的会诊请求涉及胃肠道出血的患者（52.5%），并由第一年住院医师（56.8%）提出。在 15%的请求中，医疗保健提供者缺乏对寻求会诊的患者的基本了解。相反，在 17%的会诊中，无法在患者的纸质病历/电子病历中找到相关信息。完整会诊的最强预测因素是请求者对患者既往病史的了解（P < 0.001）、对患者当前疾病的记录（P < 0.001）以及提供者的入院记录在纸质病历中的存在（P = 0.002）。在下午 5 点至 10 点之间请求的会诊被评估为更完整（P = 0.02），并且在学术年的前 3 个月中发生了更多不完整的会诊（P = 0.04）。
在分析的 16%的住院 GI 会诊请求中，关键的患者数据缺失或请求提供者不了解。请求者对患者信息的知识和记录的几个方面与住院 GI 会诊的完整性密切相关。
