Khan Abdur Rahim, Mahboob Usman, Baseer Najma
Dr. Abdur Rahim Khan MBBS, MCPS, MD, MHPE. Associate Professor of Dermatology, Khyber Girls Medical College, Hayatabad Medical Complex Peshawar, Pakistan.
Dr. Usman Mahboob, MBBS, MPH, FHEA, DHPE, Fellow FAIMER. Assistant Professor in Medical Education, Institute of Health Professions Education & Research (IHPER), Khyber Medical University (KMU), Peshawar, Pakistan.
Pak J Med Sci. 2020 May-Jun;36(4):699-704. doi: 10.12669/pjms.36.4.1642.
To explore the trend of medical call writing by doctors working in tertiary care hospitals.
A quantitative descriptive cross-sectional study was carried out to evaluate the quality of medical calls written by the doctors at three tertiary care hospitals of Peshawar, Khyber Pakhtunkhwa between June 2016 to June 2017. An instrument was developed following AMEE Guide 87. Its content validity and reliability were established by 33 consultants from twenty specialties. A total of 198 medical calls (66 each) were collected from medicine, surgery and allied specialties and evaluated on the basis of validated instrument.
During instrument development, six items with content Validity Ratio of 0.78 & Kappa value of 0.70 were deemed most significant in every medical call written. Among all the calls, the great majority (96% and 84.34%) mentioned the reason for referral (item 1) and history of presenting problem (item 2), respectively, while item 6 (explicit mention of the doctor who will receive the call) was addressed the least (17.6%). Item 3 (Result of physical examination) and 4 (what tests have been done/arranged by the referring doctor and a summary of the main findings) were stated in < 30% of the calls whereas item 5 (diagnosis/provisional diagnosis) was specified in less than half of the calls.
In this study, the written medical calls of different specialties were evaluated using specifically designed six items instrument. Unfortunately, the content of medical calls assessed was found to be inadequate probably because medical call writing is not explicitly taught at under and postgraduate levels.
探讨三级医疗保健医院医生撰写医疗会诊记录的趋势。
开展一项定量描述性横断面研究，以评估2016年6月至2017年6月期间开伯尔-普赫图赫瓦省白沙瓦市三家三级医疗保健医院医生撰写的医疗会诊记录质量。根据AMEE指南87开发了一种工具。由来自20个专业的33名顾问确定其内容效度和信度。从内科、外科及相关专业共收集了198份医疗会诊记录（各66份），并根据经过验证的工具进行评估。
在工具开发过程中，内容效度比为0.78、卡帕值为0.70的6项内容在每份撰写的医疗会诊记录中被认为最为重要。在所有会诊记录中，绝大多数（分别为96%和84.34%）提到了转诊原因（第1项）和现病史（第2项），而第6项（明确提及接听电话的医生）提及最少（17.6%）。第3项（体格检查结果）和第4项（转诊医生已进行/安排的检查及主要检查结果总结）在不到30%的会诊记录中提及，而第5项（诊断/初步诊断）在不到一半的会诊记录中明确列出。
在本研究中，使用专门设计的六项工具对不同专业的书面医疗会诊记录进行了评估。遗憾的是，评估发现医疗会诊记录的内容不充分，可能是因为本科和研究生阶段未明确教授医疗会诊记录的撰写。
