Schrans Diego, Boeckxstaens Pauline, De Sutter An, Willems Sara, Avonts Dirk, Christiaens Thierry, Matthys Jan, Kühlein Thomas
1Department of Family Medicine and Primary Health Care,Ghent University,Ghent,Belgium.
2Allgemeinmedizinisches Institut,Universitätsklinikum Erlangen,Erlangen,Germany.
Prim Health Care Res Dev. 2018 Jan;19(1):1-6. doi: 10.1017/S1463423617000391. Epub 2017 Sep 13.
Family practice aims to recognize the health problems and needs expressed by the person rather than only focusing on the disease. Documenting person-related information will facilitate both the understanding and delivery of person-focused care. Aim To explore if the patients' ideas, concerns and expectations (ICE) behind the reason for encounter (RFE) can be coded with the International Classification of Primary Care, version 2 (ICPC-2) and what kinds of codes are missing to be able to do so.
In total, 613 consultations were observed, and patients' expressions of ICE were narratively recorded. These descriptions were consequently translated to ICPC codes by two researchers. Descriptions that could not be translated were qualitatively analysed in order to identify gaps in ICPC-2.
In all, 613 consultations yielded 672 ICE expressions. Within the 123 that could not be coded with ICPC-2, eight categories could be defined: concern about the duration/time frame; concern about the evolution/severity; concern of being contagious or a danger to others; patient has no concern, but others do; expects a confirmation of something; expects a solution for the symptoms without specification of what it should be; expects a specific procedure; and expects that something is not done. Discussion Although many ICE can be registered with ICPC-2, adding eight new categories would capture almost all ICE.
家庭医疗旨在识别个体所表达的健康问题和需求，而非仅关注疾病本身。记录与个体相关的信息将有助于理解和提供以个体为中心的医疗服务。目的：探讨就诊原因（RFE）背后患者的想法、担忧和期望（ICE）能否用《国际初级保健分类第2版》（ICPC-2）进行编码，以及为实现这一目的还缺少哪些类型的编码。
共观察了613次诊疗，并对患者的ICE表达进行了叙述性记录。随后，两名研究人员将这些描述转化为ICPC编码。对无法转化的描述进行定性分析，以确定ICPC-2中的空白。
613次诊疗共产生了672个ICE表达。在无法用ICPC-2编码的123个表达中，可以定义出八类：对持续时间/时间框架的担忧；对病情发展/严重程度的担忧；担心具有传染性或对他人构成危险；患者不担心，但其他人担心；期望得到某事的确认；期望得到症状的解决办法，但未具体说明应是什么办法；期望进行特定程序；期望不做某事。讨论：虽然许多ICE可以用ICPC-2进行记录，但增加八个新类别几乎可以涵盖所有ICE。
