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老年患者电话调查与病历数据之间的一致性。

Agreement between telephone survey and medical record data for the elderly patient.

作者信息

Kvale J N, Gillanders W R, Buss T F, Gemmel D, Crenesse A, Griffiths-Marnejon J

机构信息

Division of Geriatrics, St. Elizabeth Hospital Medical Center, Youngstown, OH 44501.

出版信息

Fam Pract Res J. 1994 Mar;14(1):29-39.

PMID:8048346
Abstract

OBJECTIVE

This study compares agreement between telephone survey and ambulatory medical record data for an elderly patient population.

METHODS

Medical records and telephone survey responses are used to compare health status (chronic medical condition, symptomatology, and functional status) of 142 elderly patients randomly selected from a family practice residency and a geriatric fellowship practice. Chart abstraction was performed by two resident and two faculty physicians after a training period designed to assure high inter-reviewer reliability. Telephone surveys were completed by two professional interviewers. Health status measures were taken from standard, published instruments. The kappa statistic was used to measure the agreement between medical record and survey data.

RESULTS

Overall, there is little agreement between the medical record and the telephone survey results on chronic medical condition, symptomatology, and functional status.

CONCLUSIONS

Medical records abstractions and telephone survey methodologies did not yield comparable health status data when applied to the same elderly patient population. Functional status assessment and symptomatology are particularly problematic, but even the presence or absence of chronic diseases is often inconsistent in the two data sources.

摘要

目的

本研究比较了针对老年患者群体的电话调查与门诊病历数据之间的一致性。

方法

利用病历和电话调查回复,比较从家庭医疗住院医师培训项目和老年医学专科培训项目中随机选取的142例老年患者的健康状况(慢性疾病状况、症状学和功能状态)。在经过一个旨在确保高审查者间可靠性的培训期后,由两名住院医师和两名指导医师进行病历摘要提取。电话调查由两名专业访谈员完成。健康状况测量采用标准的、已发表的工具。kappa统计量用于衡量病历与调查数据之间的一致性。

结果

总体而言,病历与电话调查结果在慢性疾病状况、症状学和功能状态方面几乎没有一致性。

结论

当应用于同一老年患者群体时,病历摘要提取和电话调查方法并未得出可比的健康状况数据。功能状态评估和症状学尤其成问题,但即使是两种数据来源中慢性疾病的有无也常常不一致。

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