Bear Alexandria, Thiel Elizabeth
1 Palliative Care Section, Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
2 Palliative Care Section-Community Health Division, Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
J Palliat Care. 2018 Jan;33(1):5-8. doi: 10.1177/0825859717746273. Epub 2017 Dec 20.
Medical decision-making has evolved to the modern model of shared decision-making among patients, surrogate decision-makers, and medical providers. As such, informed consent discussions with critically ill patients often should include larger discussions relating to values and goals of care. Documentation of care options and prognosis serves as an important component of electronic communication relating to patient preferences among care providers.
This retrospective chart review study sought to evaluate the prevalence of documentation of critical data, care options, prognosis, and medical plan, within primary team and palliative care consult team documentation.
Three hundred two electronic medical records were reviewed. There was a significant difference in documentation between palliative care and primary teams for prognosis (83% vs 32%, P < .001), care options (82% vs 50%, P < .001), and care plan (82% vs 46%, P < .001).
Our retrospective chart review study demonstrated a significant difference in documentation between primary and palliative care teams. We acknowledge that review of documentation cannot be extrapolated to the presence or absence of conversations between providers and patients and/or surrogates. Additional studies to evaluate this connection would be advantageous.
医疗决策已发展为患者、替代决策者和医疗服务提供者之间共同决策的现代模式。因此，与重症患者进行的知情同意讨论通常应包括与护理价值观和目标相关的更广泛讨论。护理选择和预后的记录是护理提供者之间与患者偏好相关的电子通信的重要组成部分。
这项回顾性病历审查研究旨在评估主要团队和姑息治疗咨询团队的文档中关键数据、护理选择、预后和医疗计划的记录发生率。
共审查了302份电子病历。姑息治疗团队和主要团队在预后记录（83%对32%，P<.001）、护理选择记录（82%对50%，P<.001）和护理计划记录（82%对46%，P<.001）方面存在显著差异。
我们的回顾性病历审查研究表明，主要护理团队和姑息治疗团队在文档记录方面存在显著差异。我们承认，对文档记录的审查不能推断出提供者与患者和/或替代者之间是否存在对话。进一步评估这种联系的研究将是有益的。
