Imperial College Healthcare NHS Trust, Hammersmith Hospital, , London, UK.
Postgrad Med J. 2013 Dec;89(1058):693-7. doi: 10.1136/postgradmedj-2012-131410. Epub 2013 Aug 2.
The content of medical records is a potential source of miscommunication between clinicians. Doctors' written entries have been criticised for their illegibility and ambiguity, but no studies have examined doctors' drawings that are commonly used for recording auscultation findings.
To compare doctors' drawings of auscultation findings, based on identical clinical information.
Doctors at the Royal London Hospital and a group of London based general practitioners (GPs) documented a respiratory examination with a drawing of the auscultation findings of bilateral mid and lower zone wheeze and right lower zone crackles. The graphical properties of each drawing were examined and the use of written captions and labels recorded. Drawings were classified into styles according to the use of symbols (defined as discrete characters or icons) and shading (cross-hatching, speckling or darkening) to depict the auscultation findings. The study was conducted between September and November 2011.
Sixty-nine hospital doctors and 13 GPs participated. Ten drawing styles were identified from 78 completed drawings. Ten distinct symbols and a range of shading techniques were used. The most frequent style (21% of drawings) combined 'X' symbols representing crackles with musical notes for wheeze. There was inconsistency of representation across the drawings. Forty-seven (60%) drawings used an 'X' symbol exclusively to represent crackles, but six (8%) used 'X' only to represent wheeze, and 10 (13%) used 'X' to represent both findings. 91% of participants included captions or labels with their drawing.
There was wide variation in doctors' drawings of identical auscultation findings, and inconsistency in the meaning of symbols both between and within drawings. Doctors risk incorrectly interpreting each other's drawings when they are not effectively labelled. We recommend doctors consider using a written description instead, or draw different findings with distinct symbols or shading, labelling all findings clearly.
病历内容是临床医生之间潜在的沟通障碍。医生的书面记录因难以辨认和模糊不清而受到批评，但尚未有研究检查医生用于记录听诊结果的常见绘图。
比较基于相同临床信息的医生听诊结果绘图。
伦敦皇家医院的医生和一组伦敦的全科医生（GP）记录了一项呼吸检查，其中包括双侧中、下区哮鸣音和右下区爆裂音的听诊结果绘图。检查了每个绘图的图形属性，并记录了使用文字说明和标签的情况。根据符号（定义为离散字符或图标）和阴影（交叉影线、点画或变暗）的使用情况，将绘图分类为不同的风格，以描绘听诊结果。研究于 2011 年 9 月至 11 月进行。
共有 69 名医院医生和 13 名 GP 参与了研究。从 78 份完整的绘图中确定了 10 种绘图风格。使用了 10 个独特的符号和一系列阴影技术。最常见的风格（21%的绘图）将代表爆裂音的“X”符号与代表哮鸣音的音符组合在一起。绘图之间存在不一致的表示。47%（60%）的绘图仅使用“X”符号表示爆裂音，但有 6%（8%）的绘图仅使用“X”符号表示哮鸣音，10%（13%）的绘图使用“X”符号表示两种发现。91%的参与者在绘图中包含说明或标签。
医生对相同听诊结果的绘图存在广泛的差异，符号的含义在绘图之间和内部都不一致。如果绘图没有有效标记，医生可能会错误地解释彼此的绘图。我们建议医生考虑使用书面描述代替，或使用不同的符号或阴影绘制不同的发现，并清楚地标记所有发现。
