Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, PO Box 196, Groningen, 9700 AD, The Netherlands.
BMC Prim Care. 2023 Oct 23;24(1):217. doi: 10.1186/s12875-023-02167-6.
For diagnostic research on appendicitis in registration data, insight is needed in the way GPs generate medical records. We aimed to reach a consensus on the features that GPs consider important in the consultation and medical records when evaluating a child with suspected appendicitis.
We performed a three-round Delphi study among Dutch GPs selected by purposive sampling. An initial feature list was created based on a literature search and features in the relevant Dutch guideline. Finally, using a vignette describing a child who needed later reassessment, we asked participants to complete an online questionnaire about which consultation features should be addressed and recorded.
A literature review and Dutch guideline yielded 95 consultation features. All three rounds were completed by 22 GPs, with the final consensus list containing 26 symptoms, 29 physical assessments and signs, 2 additional tests, and 8 further actions (including safety-netting, i.e., informing the patient about when to contact the GP again). Of these, participants reached consensus that 37 should be actively addressed and that 20 need to be recorded if findings are negative.
GPs agreed that negative findings do not need to be recorded for most features and that records should include the prognostic and safety-netting advice given. The results have implications in three main domains: for research, that negative findings are likely to be missing; for medicolegal purposes, that documentation cannot be expected to be complete; and for clinical practice, that safety-netting advice should be given and documented.
在注册数据中进行阑尾炎诊断研究时，需要深入了解全科医生生成医疗记录的方式。我们旨在就全科医生在评估疑似阑尾炎的儿童时，在咨询和医疗记录中认为重要的特征达成共识。
我们在荷兰通过目的性抽样选择的全科医生中进行了三轮 Delphi 研究。最初的特征列表是根据文献检索和相关荷兰指南中的特征创建的。最后，使用描述需要进一步评估的儿童的案例，我们要求参与者在线填写一份问卷，内容是哪些咨询特征应被提及和记录。
文献综述和荷兰指南共产生了 95 个咨询特征。所有三轮都由 22 名全科医生完成，最终的共识列表包含 26 个症状、29 个身体评估和体征、2 项额外检查和 8 项进一步行动（包括安全网，即告知患者何时再次联系全科医生）。其中，参与者达成共识，认为 37 项应积极处理，如果发现为阴性，则 20 项需要记录。
全科医生一致认为，大多数特征的阴性发现无需记录，并且记录应包括提供的预后和安全网建议。研究结果对三个主要领域具有重要意义：对于研究而言，阴性发现可能会缺失；对于医疗法律目的而言，预计无法完成完整的记录；对于临床实践而言，应提供并记录安全网建议。
