评估评估——开发和部署一种新的工具，用于评估临床记录的诊断评估质量。
Assessing the Assessment-Developing and Deploying a Novel Tool for Evaluating Clinical Notes' Diagnostic Assessment Quality.
机构信息
Center for Patient Safety Research and Practice, Department of Medicine, Brigham and Women's Hospital, 3Rd Floor General Medicine, 1620 Tremont St, Boston, MA, 02120, USA.
Haifa University, Haifa, Israel.
出版信息
J Gen Intern Med. 2023 Jul;38(9):2123-2129. doi: 10.1007/s11606-023-08085-8. Epub 2023 Feb 28.
BACKGROUND
Ambulatory diagnostic errors are increasingly being recognized as an important quality and safety issue, and while measures of diagnostic quality have been sought, tools to evaluate diagnostic assessments in the medical record are lacking.
OBJECTIVE
To develop and test a tool to measure diagnostic assessment note quality in primary care urgent encounters and identify common elements and areas for improvement in diagnostic assessment.
DESIGN
Retrospective chart review of urgent care encounters at an urban academic setting.
PARTICIPANTS
Primary care physicians.
MAIN MEASURES
The Assessing the Assessment (ATA) instrument was evaluated for inter-rater reliability, internal consistency, and findings from its application to EHR notes.
KEY RESULTS
ATA had reasonable performance characteristics (kappa 0.63, overall Cronbach's alpha 0.76). Variability in diagnostic assessment was seen in several domains. Two components of situational awareness tended to be well-documented ("Don't miss diagnoses" present in 84% of charts, red flag symptoms in 87%), while Psychosocial context was present only 18% of the time.
CONCLUSIONS
The ATA tool is a promising framework for assessing and identifying areas for improvement in diagnostic assessments documented in clinical encounters.
背景
越来越多的人认识到门诊诊断错误是一个重要的质量和安全问题，虽然已经寻求了诊断质量的衡量标准，但缺乏评估病历中诊断评估的工具。
目的
开发和测试一种用于测量初级保健紧急就诊中诊断评估记录质量的工具，并确定诊断评估中常见的要素和需要改进的领域。
设计
对城市学术环境中的紧急就诊进行回顾性图表审查。
参与者
初级保健医生。
主要措施
评估评估工具（ATA）在评估记录中的内部一致性、信度和应用结果。
主要结果
ATA 具有合理的性能特征（kappa 值为 0.63，整体 Cronbach's alpha 为 0.76）。在几个领域中可以看到诊断评估的变异性。情境意识的两个组成部分往往记录得很好（84%的图表中有“不要遗漏诊断”，87%的图表中有警示症状），而心理社会背景只出现了 18%的时间。
结论
ATA 工具是评估和确定临床就诊中诊断评估记录中需要改进的领域的有前途的框架。
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