Department of Medicine Winthrop University Hospital , Mineola, NY 11501.
Department of Medical Informatics Winthrop University Hospital , Mineola, NY 11501.
Appl Clin Inform. 2013 Nov 13;4(4):528-40. doi: 10.4338/ACI-2013-07-RA-0048. eCollection 2013.
Kidney disease is under-documented in physician notes. The use of template-guided notes may improve physician recognition of kidney disease early in training.
The objective of this study was to determine whether a computerized inpatient renal template note with clinical decision support improves resident knowledge and documentation of kidney disease.
In this prospective study, first year medical residents were encouraged to use the renal template note for documentation over a one-month period. The renal template note included an option for classification of acute kidney injury (AKI) and chronic kidney disease (CKD) categories with a link to standard classifications. Pre- and post-knowledge of AKI and CKD categories was tested with a quiz and surveys of resident experience with the intervention were conducted. Appropriate AKI and/or CKD classification was determined in 100 renal template notes and 112 comparable historical internal medicine resident progress notes from approximately one year prior.
2,435 inpatient encounters amongst 15 residents who participated were documented using the renal template note. A significantly higher percent of residents correctly staged earlier stage CKD (CKD3) using the renal template note compared to historical notes (9/46 vs. 0/33, p<0.01). Documentation of AKI and more advanced CKD stages (CKD4 and 5) did not improve. Knowledge based on quiz scores increased modestly but was not significant. The renal template note was well received by residents and was perceived as helping improve knowledge and documentation of kidney disease.
The renal template note significantly improved staging of earlier stage CKD (CKD3) with a modest but non-significant improvement in resident knowledge. Given the importance of early recognition and treatment of CKD, future studies should focus on teaching early recognition using template notes with supplemental educational interventions.
肾脏疾病在医生的记录中记录不足。使用模板指导的记录可能会提高医生在培训早期识别肾脏疾病的能力。
本研究的目的是确定计算机化的住院肾脏模板记录与临床决策支持是否能提高住院医师对肾脏疾病的知识和记录。
在这项前瞻性研究中，鼓励第一年的住院医师在一个月的时间内使用肾脏模板记录进行记录。肾脏模板记录包括急性肾损伤（AKI）和慢性肾脏病（CKD）类别的分类选项，并链接到标准分类。通过测验测试 AKI 和 CKD 类别的预先和后知知识，并对干预措施的住院医师经验进行调查。在 100 份肾脏模板记录和大约一年前的 112 份内部医学住院医师进展记录中确定了适当的 AKI 和/或 CKD 分类。
15 名参与的住院医师共记录了 2435 例住院患者。与历史记录相比，使用肾脏模板记录的住院医师在更早阶段 CKD（CKD3）的分期中，正确分期的比例显著更高（9/46 比 0/33，p<0.01）。AKI 和更晚期 CKD 阶段（CKD4 和 5）的记录没有改善。基于测验成绩的知识略有增加，但没有显著意义。住院医师对肾脏模板记录的评价很好，认为它有助于提高对肾脏疾病的知识和记录。
肾脏模板记录显著改善了早期 CKD（CKD3）的分期，住院医师的知识略有但无显著提高。鉴于早期识别和治疗 CKD 的重要性，未来的研究应侧重于使用模板记录和补充教育干预措施来教授早期识别。
