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住院医师与患者诊疗过程的计算机跟踪程序评估

Evaluation of a computer tracking program for resident-patient encounters.

作者信息

Rowe B H, Ryan D T, Mulloy J V

机构信息

Northeastern Ontario Family Medicine Program, Laurentian University, Sudbury, ON.

出版信息

Can Fam Physician. 1995 Dec;41:2113-20.

Abstract

OBJECTIVE

To examine the effectiveness of a formal tracking system for residents' clinical experiences.

DESIGN

We examined three shifts, selected at random, for each resident (without residents' knowledge) during emergency rotations. Information from patient charts was compared with residents' computerized records for rotation (location and preceptor) and patient (age, sex, diagnosis, and procedure) information.

SETTING

The Northeastern Ontario Family Medicine Program, a program designed to provide remote, rural, and northern resident experience.

PARTICIPANTS

First-, second-, and third-year residents on emergency rotations in the academic years 1992 to 1994.

MAIN OUTCOME MEASURES

Compliance, reliability, and validity of tracking records.

RESULTS

Residents recorded patient encounters 88% of the time. Compliance with rotation information was high (100% rotation, 94% preceptor). Agreement on patient age and sex was high. Procedure compliance was somewhat lower (83%). Intrarater reliability (91%) and inter-rater reliability (78%) are acceptably high, as is validity when compared with a gold standard entry (88%).

CONCLUSIONS

Regular entry of reliable and valid data is facilitated by the computerized resident-patient encounter tracking program. This computer tool should prove useful for multilevel program evaluation in the future.

摘要

目的

评估住院医师临床经验正式追踪系统的有效性。

设计

在急诊轮转期间,我们随机选取每位住院医师的三个班次(住院医师不知情)。将病历信息与住院医师轮转(地点和带教老师)及患者(年龄、性别、诊断和操作)信息的计算机记录进行比较。

地点

安大略省东北部家庭医学项目,该项目旨在提供偏远、农村和北部地区的住院医师培训经历。

参与者

1992年至1994学年参与急诊轮转的一、二、三年级住院医师。

主要观察指标

追踪记录的依从性、可靠性和有效性。

结果

住院医师记录患者诊疗情况的时间占比为88%。轮转信息的依从性很高(轮转信息100%,带教老师信息94%)。患者年龄和性别的一致性很高。操作依从性略低(83%)。评分者内信度(91%)和评分者间信度(78%)处于可接受的较高水平,与金标准录入相比,效度也较高(88%)。

结论

住院医师-患者诊疗情况计算机追踪程序有助于定期录入可靠且有效的数据。这种计算机工具在未来的多层次项目评估中应会很有用。

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本文引用的文献

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Documentation of inpatient experiences of resident physicians.住院医师住院经历的记录。
J Med Educ. 1985 May;60(5):408-10. doi: 10.1097/00001888-198505000-00010.

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