Duke University School of Medicine (L.S.), Durham, North Carolina, USA.
Division of General Internal Medicine, Department of Medicine (N.S., J.W., D.C., K.S., J.M.), Duke University School of Medicine, Durham, North Carolina, USA.
J Pain Symptom Manage. 2023 Aug;66(2):123-136. doi: 10.1016/j.jpainsymman.2023.04.015. Epub 2023 Apr 18.
While professional societies and expert panels have recommended quality indicators related to advance care planning (ACP) documentation, including using structured documentation templates, it is unclear how clinicians document these conversations.
To explore how clinicians document ACP, specifically, which components of these conversations are documented.
A codebook was developed based on existing frameworks for ACP conversations and documentation. ACP documentation from a hospital medicine quality improvement project conducted from November 2019 to April 2021 were included and assessed. Documentation was examined for the presence or absence of each component within the coding schema. Clinician documented ACP using three different note types: template (only template prompts were used), template plus (authors added additional text to the template), and free text only. ACP note components were analyzed by note type and author department.
A total of 182 ACP notes were identified and reviewed. The most common note type was template plus (58%), followed by free text (28%) and template (14%). The most frequent components across all note types were: important relationships to patient (92%), and discussion of life-sustaining treatment preferences (87%). There was considerable heterogeneity in the components across note types. The presence of components focused on treatment decisions and legal paperwork differed significantly between note types (P < 0.05). Components on preference for medical information, emotional state, or spiritual support were rarely included across all note types.
This study provides a preliminary exploration of ACP documentation and found that templates may influence what information is documented after an ACP conversation.
虽然专业协会和专家小组已经推荐了与预先医疗指示（ACP）文件记录相关的质量指标，包括使用结构化文件记录模板，但临床医生如何记录这些对话尚不清楚。
探索临床医生如何记录 ACP，特别是记录这些对话的哪些部分。
根据现有的 ACP 对话和文件记录框架，制定了一个代码本。纳入并评估了 2019 年 11 月至 2021 年 4 月期间进行的医院医学质量改进项目中的 ACP 文件记录。在编码方案中检查了每个组件的存在或缺失。临床医生使用三种不同的记录类型记录 ACP：模板（仅使用模板提示）、模板加（作者在模板中添加了其他文本）和仅自由文本。按记录类型和作者科室分析 ACP 记录组件。
共确定并审查了 182 份 ACP 记录。最常见的记录类型是模板加（58%），其次是自由文本（28%）和模板（14%）。所有记录类型中最常见的组件是：与患者的重要关系（92%）和讨论维持生命的治疗偏好（87%）。在记录类型之间，组件在治疗决策和法律文件方面存在相当大的异质性。记录类型之间的组件存在显著差异（P<0.05）。在所有记录类型中，很少记录有关治疗信息、情绪状态或精神支持的偏好。
本研究初步探讨了 ACP 文件记录，发现模板可能会影响 ACP 对话后记录的信息。
