University of Colorado Denver School of Medicine, Department of Medicine.
Appl Clin Inform. 2010 Sep 15;1(3):318-30. doi: 10.4338/ACI-2010-04-RA-0022. Print 2010.
To document the perceived frequency, type, and impact of unavailable ("missing") clinical information during pediatric emergency and general ambulatory encounters.
This prospective cohort set in the Emergency Department and General Ambulatory Pediatric Clinic at The Children's Hospital, Aurora, CO, assessed pediatric attending physician perceptions regarding missing information at emergency and general ambulatory encounters. The main outcome measures were the frequency of perceived missing information; its presumed location; time spent seeking; and the perceived effects on resource utilization and overall quality of care.
Pediatric physicians reported missing information for 2% of emergency and 22% of general ambulatory encounters. Types of missing information at general ambulatory visits included immunization (34% of types), general past medical (29%), and disease or visit specific histories (13%). Missing information at ambulatory visits was sought 20% of the time, obtained 4% of the time, and rated "somewhat or very important for today's care" (73% of the time) and "somewhat or very important for future care" (84% of the time). For encounters with unattained missing information, physicians reported adverse affects on the efficiency of the visit (64%), physician's confidence in care (33%), patient/family satisfaction (17%), disposition decisions (8%), and recommended additional treatment (38%), laboratory studies (16%), and imaging (12%). For 57% of encounters with missing information, physicians perceived an adverse effect on overall quality of care. Missing information was associated with not having a primary care visit at TCH within 12 months of the encounter, (OR 2.8; 95% CI, 1.7, 4.5).
Pediatric physicians more commonly experience missing information at general ambulatory visits than emergency visits and report that missing information adversely impacts quality, efficiency, their confidence in care, patient and family satisfaction, and leads to potentially redundant resource utilization.
记录儿科急诊和普通门诊就诊时无法获得（“缺失”）的临床信息的感知频率、类型和影响。
这项前瞻性队列研究在科罗拉多州奥罗拉儿童医院的急诊室和普通儿科门诊进行，评估了儿科主治医生对急诊和普通门诊就诊时缺失信息的看法。主要结局指标是感知到的缺失信息的频率；其假定位置；寻找信息所花费的时间；以及对资源利用和整体护理质量的感知影响。
儿科医生报告说，在 2%的急诊和 22%的普通门诊就诊中存在缺失信息。普通门诊就诊中缺失的信息类型包括免疫接种（34%的类型）、一般既往病史（29%）和疾病或就诊特定病史（13%）。在普通门诊就诊中，有 20%的时间会寻找缺失信息，4%的时间会找到缺失信息，73%的时间会认为这些信息“对今天的护理有些或非常重要”，84%的时间会认为这些信息“对未来的护理有些或非常重要”。对于未能获得缺失信息的就诊，医生报告说这会对就诊效率（64%）、医生对护理的信心（33%）、患者/家属满意度（17%）、处置决策（8%）以及推荐的额外治疗（38%）、实验室检查（16%）和影像学检查（12%）产生不利影响。对于 57%的存在缺失信息的就诊，医生认为这会对整体护理质量产生不利影响。缺失信息与在就诊后 12 个月内没有在 TCH 进行初级保健就诊有关（OR 2.8；95%CI，1.7，4.5）。
儿科医生在普通门诊就诊中比在急诊就诊中更常遇到缺失信息，他们报告说缺失信息会对质量、效率、他们对护理的信心、患者和家属的满意度产生不利影响，并导致潜在的资源浪费。
