Dullard Brittney, Saunders Gabrielle H
Speech, Language, and Hearing Sciences, University of Connecticut, Mansfield.
National Center for Rehabilitative Auditory Research, Portland VA Medical Center, Portland, Oregon.
Gerontologist. 2016 Apr;56(2):313-7. doi: 10.1093/geront/gnu032. Epub 2014 May 20.
To examine the documentation of sensory impairment in the electronic medical records (EMRs) of Veterans with both hearing and vision losses (dual sensory impairment [DSI]).
A retrospective chart review of the EMRs of 20 patients with DSI was conducted. Providers' documentation of the presence of sensory impairment, the use of assistive technology during clinical appointments, and the content of notes mentioning communication issues were extracted from each chart note in the EMR for the prior 6 years.
Primary care providers documented DSI in 50% of EMRs, vision loss alone in 40%, and hearing loss alone in 10% of EMRs. Audiologists documented vision loss in 50% of cases, whereas ophthalmologists/optometrists documented hearing loss in 15% of cases. Examination of two selected cases illustrates that care can be compromised when providers do not take note of sensory impairments during planning and provision of clinical care.
Sensory impairment is poorly documented by most providers in EMRs. This is alarming because vision and hearing affect patient-physician communication and the use of medical interventions. The results of this study raise awareness about the need to document the presence of sensory impairments and use the information when planning treatment for individuals with DSI.
检查患有听力和视力丧失（双重感官障碍[DSI]）的退伍军人电子病历（EMR）中感官障碍的记录情况。
对20例DSI患者的电子病历进行回顾性图表审查。从电子病历中过去6年的每份病历记录中提取医疗服务提供者对感官障碍存在情况的记录、临床预约期间辅助技术的使用情况以及提及沟通问题的记录内容。
初级保健提供者在50%的电子病历中记录了DSI，仅视力丧失记录在40%的病历中，仅听力丧失记录在10%的病历中。听力学家在50%的病例中记录了视力丧失，而眼科医生/验光师在15%的病例中记录了听力丧失。对两个选定病例的检查表明，当医疗服务提供者在规划和提供临床护理时未注意到感官障碍时，护理可能会受到影响。
大多数医疗服务提供者在电子病历中对感官障碍的记录不足。这令人担忧，因为视力和听力会影响医患沟通以及医疗干预措施的使用。本研究结果提高了人们对记录感官障碍存在情况以及在为DSI患者规划治疗时使用该信息的必要性的认识。
