化疗所致恶心和呕吐文档的数据质量。
Data Quality of Chemotherapy-Induced Nausea and Vomiting Documentation.
机构信息
School of Nursing, Columbia University, New York, New York, United States.
Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York, United States.
出版信息
Appl Clin Inform. 2021 Mar;12(2):320-328. doi: 10.1055/s-0041-1728698. Epub 2021 Apr 21.
OBJECTIVE
The objective of the study was to characterize the completeness and concordance of the electronic health record (EHR) documentation of cancer symptoms among multidisciplinary health care professionals.
METHODS
We examined the EHRs of children, adolescents, and young adults who received highly emetogenic chemotherapy and characterized the completeness and concordance of chemotherapy-induced nausea and vomiting (CINV) documentation by clinician type and by the International Classification of Diseases 10th Revision (ICD-10) coding choice.
RESULTS
The EHRs of 127 patients, comprising 870 patient notes, were abstracted and reviewed. A CINV assessment was documented by prescribers in 75% of patients, and by nurses in 58% of patients. Of the 60 encounters where both prescribers and nurses documented, 72% agreed on the presence/absence of CINV.
CONCLUSION
Most patients receiving highly emetogenic chemotherapy had a documented assessment of CINV; however, many had incomplete or discordant documentation of CINV from different providers by role, implying the importance of incorporating pragmatic knowledge of EHR documentation patterns among multidisciplinary health professionals for EHR phenotyping and clinical decision support systems directed toward cancer-related symptom management.
目的
本研究旨在描述多学科医疗保健专业人员电子健康记录（EHR）中癌症症状记录的完整性和一致性。
方法
我们检查了接受高致吐性化疗的儿童、青少年和年轻成人的 EHR，并根据临床医生类型和国际疾病分类第 10 版（ICD-10）编码选择，描述了化疗引起的恶心和呕吐（CINV）记录的完整性和一致性。
结果
共摘录和审查了 127 名患者的 870 份病历。75%的患者由处方医生记录了 CINV 评估，58%的患者由护士记录。在 60 次同时记录了处方医生和护士的就诊中，72%的就诊记录了 CINV 的存在/不存在。
结论
大多数接受高致吐性化疗的患者都有 CINV 评估的记录；然而，许多患者的 CINV 记录不完整或不一致，不同提供者的记录方式不同，这意味着多学科医疗保健专业人员需要了解 EHR 记录模式的实际知识，以便对 EHR 进行表型分析，并为癌症相关症状管理开发临床决策支持系统。
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