Boohaker E A, Ward R E, Uman J E, McCarthy B D
Department of Medicine, Henry Ford Hospital, Detroit, Mich., USA.
Arch Intern Med. 1996 Feb 12;156(3):327-31.
To investigate physician practices in the handling of patients' test results from the time the test was ordered until the time any required follow-up was completed.
Survey of 161 attending physicians and 101 residents in family practice and internal medicine practicing at a large urban teaching hospital and 21 suburban primary care practices in Southeastern Michigan. The survey included questions about physician demographics, and whether physicians have methods for ensuring that (1) the results of all tests ordered are received, (2) all patients are notified of results, (3) all patient notification is documented, and (4) all required follow-up is done. Physicians were also asked to self-rate the reliability of their methods and the importance of various steps in the handling of patients' test results.
The response rate was 79% for both attending physicians and residents. Approximately 17% to 32% of physicians reported having no reliable method to make sure that the results of all tests ordered are received. One third of physicians do not always notify patients of abnormal results. The most common reasons reported for not notifying patients were that the results were trivial and that the patient was expected to return to the clinic soon. Residents were significantly less likely to document notifying patients of abnormal results (P < .001). Only 23% of physicians reported having a reliable method for identifying patients overdue for follow-up.
Lack of methods to ensure that the results of tests ordered were received, dependence on follow-up visits to inform patients of results, and lack of documentation were relatively common among physicians surveyed. These could lead to an increased risk of malpractice litigation and suboptimal patient care.
调查医生从开出检查医嘱到完成所有必要的后续跟进这段时间内处理患者检查结果的行为。
对一家大型城市教学医院的161名主治医师和101名家庭医学与内科住院医师，以及密歇根州东南部21家郊区初级保健机构进行调查。调查问题包括医生的人口统计学信息，以及医生是否有方法确保：（1）收到所有开出检查的结果；（2）通知所有患者检查结果；（3）记录所有患者通知情况；（4）完成所有必要的后续跟进。还要求医生对其方法的可靠性以及处理患者检查结果各步骤的重要性进行自我评估。
主治医师和住院医师的回复率均为79%。约17%至32%的医生表示没有可靠方法确保收到所有开出检查的结果。三分之一的医生并非总是将异常结果通知患者。未通知患者的最常见原因是结果无关紧要以及预计患者很快会返回诊所。住院医师记录通知患者异常结果的可能性显著更低（P < .001）。只有23%的医生表示有可靠方法识别逾期未进行后续跟进的患者。
在所调查的医生中，缺乏确保收到开出检查结果的方法、依赖复诊告知患者结果以及缺乏记录情况较为常见。这些可能会增加医疗事故诉讼风险并导致患者护理欠佳。
