Dey Mrinalini, Buhagiar Kurt, Jabbar Farid
Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK.
Research Department, East London NHS Foundation Trust, London, UK.
BMC Res Notes. 2019 Sep 4;12(1):558. doi: 10.1186/s13104-019-4596-2.
Medical records are critical to patient care, but often contain incomplete information. In UK hospitals, record-keeping is traditionally undertaken by junior doctors, who are increasingly completing early-career placements in psychiatry, but negative attitudes towards psychiatry may affect their performance. Little is known about the accuracy of medical records in psychiatry in general. This study aimed to evaluate the accuracy of Electronic Medical Records (EMRs) pertinent to clinical decision-making ("rationale") for prescribing completed by junior doctors during a psychiatry placement, focusing on the differences between psychotropic vs. non-psychotropic drugs and the temporal association during their placement.
EMRs of 276 participants yielding 780 ward round entries were analysed, 100% of which were completed by Foundation Year or General Practice specialty training junior doctors rather than more senior clinicians. Compared with non-psychotropic drugs, documentation of prescribing rationale for psychotropic drugs was less likely (OR = 0.24, 95% CI 0.16-0.36, p < 0.001). The rate of rationale documentation significantly declined over time especially for psychotropic drugs (p < 0.001). Prescribing documentation of non-psychotropic drugs for people with mental illness is paradoxically more accurate than that of psychotropic drugs. Early-career junior doctors are therefore increasingly shaping EMRs of people receiving psychiatric care.
病历对患者护理至关重要，但往往包含不完整信息。在英国医院，传统上由初级医生负责记录病历，他们越来越多地在精神病学领域完成早期职业实习，但对精神病学的负面态度可能会影响他们的工作表现。总体而言，关于精神病学病历的准确性知之甚少。本研究旨在评估初级医生在精神病学实习期间完成的与临床决策（“理由”）相关的电子病历（EMR）的准确性，重点关注精神药物与非精神药物之间的差异以及实习期间的时间关联。
分析了276名参与者的电子病历，产生了780条查房记录，其中100%由基础年或全科专业培训初级医生而非资深临床医生完成。与非精神药物相比，精神药物处方理由的记录可能性较小（OR = 0.24，95% CI 0.16 - 0.36，p < 0.001）。理由记录率随时间显著下降，尤其是精神药物（p < 0.001）。矛盾的是，为精神疾病患者开具非精神药物的处方记录比精神药物更准确。因此，早期职业初级医生越来越多地塑造接受精神科护理患者的电子病历。
