药师主导的抗凝门诊与医生主导的抗凝门诊的医疗文档比较：一项回顾性研究。
Comparison of medical documentation between pharmacist-led anticoagulation clinics and physician-led anticoagulation clinics: A retrospective study.
作者信息
Almuqbil Mansour, Alturki Haya, Al Juffali Lobna, Al-Otaibi Nourah, Awaad Nada, Alkhudair Nora, Alhammad Abdullah M, Alsuwayni Bashayr, Alrouwaijeh Sara, Aljawadi Mohammad, Alhossan Abdulaziz, Asdaq Syed Mohammed Basheeruddin
机构信息
Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia.
Department of pharmacy services, Prince Sultan Military Medical City, Riyadh, Saudi Arabia.
出版信息
Saudi Pharm J. 2023 Nov;31(11):101795. doi: 10.1016/j.jsps.2023.101795. Epub 2023 Sep 22.
BACKGROUND AND OBJECTIVES
High-quality documentation is critical in medical settings for providing safe patient care. This study was done with the objective of assessing the standard of medical records in anticoagulation clinics and investigating the distinctions between notes written by pharmacists and physicians.
METHODS
A retrospective cross-sectional analysis of data from electronic health records (EHRs) was performed on patients who received anticoagulation and were observed at anticoagulation clinics from October to December 2020. Patients were monitored in two anticoagulation clinics, one administered by pharmacists and the other by physicians. The quality of the documentation was assessed using a score, and the note was assigned one of five categories according to its score: very good, good, average, poor, and very poor. The data was analyzed using Stata/SE 13.1. P value<0.05 was considered significant in all analytical tests.
RESULTS
A total of 331 patients were included. While 160 patients (48.3%) were followed by the physician-led clinic, 171 (51.6%) were by the pharmacist-led clinic. The average age of the patients was 54 ± 15. 60.73% of them were female, and 90.3% of them were Saudi nationals. Warfarin was the most widely used anticoagulant (70%), followed by rivaroxaban (15.7%). Compared to physicians, pharmacists demonstrated very strong documentation (54% vs. 18%). The examination of the variables considered in the study revealed that physicians had significantly less drug-drug interaction documentation (17 vs. 71 times) or drug-food interaction documentation (23 vs. 71 times) than pharmacists. In terms of follow-up frequency, pharmacists were found to adhere to the clinic protocol (150 times) more frequently than physicians (104 times). However, there was no significant difference in therapeutic plan documentation between the two groups. ( = 0.416).
CONCLUSION
Pharmacists were more comprehensive in their documentation than physicians in anticoagulation clinics. Unified clinic documentation can ensure consistent documentation within EHRs across all disciplines.
背景与目的
高质量的文档记录在医疗环境中对于提供安全的患者护理至关重要。本研究旨在评估抗凝门诊的病历标准，并调查药剂师和医生所写记录之间的差异。
方法
对2020年10月至12月在抗凝门诊接受抗凝治疗并接受观察的患者的电子健康记录（EHR）数据进行回顾性横断面分析。在两个抗凝门诊对患者进行监测，一个由药剂师管理，另一个由医生管理。使用评分评估文档质量，并根据评分将记录分为五个类别之一：非常好、好、一般、差和非常差。使用Stata/SE 13.1分析数据。在所有分析测试中，P值<0.05被认为具有统计学意义。
结果
共纳入331例患者。其中，160例患者（48.3%）由医生主导的门诊随访，171例患者（51.6%）由药剂师主导的门诊随访。患者的平均年龄为54±15岁。其中60.73%为女性，90.3%为沙特国民。华法林是使用最广泛的抗凝剂（70%），其次是利伐沙班（15.7%）。与医生相比，药剂师的文档记录非常完善（54%对18%）。对研究中考虑的变量进行检查发现，医生的药物相互作用文档记录（17次对71次）或药物与食物相互作用文档记录（23次对71次）明显少于药剂师。在随访频率方面，发现药剂师比医生更频繁地遵守门诊协议（150次对104次）。然而，两组之间的治疗计划文档记录没有显著差异（P=0.416）。
结论
在抗凝门诊，药剂师的文档记录比医生更全面。统一的门诊文档记录可以确保电子健康记录中所有学科的文档记录一致。
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