Sulmasy D P, Dwyer M, Marx E
Center for Clinical Bioethics, Georgetown University Medical Center, Washington, DC, USA.
J Med Ethics. 1996 Dec;22(6):344-8. doi: 10.1136/jme.22.6.344.
To study the accuracy of reviewing ward notes (chart review) as a measure of the quality of care rendered to patients with "Do Not Resuscitate" (DNR) orders.
We reviewed the charts of 19 consecutive, competent inpatients with DNR orders for evidence that the staff addressed a broad range of patient care needs called Concurrent Care Concerns (CCCs), such as withholding treatments other than resuscitation itself, and attention to patient comfort needs. We then interviewed the patient, consultant physician, house officer, and primary nurse and compared the ward notes with the understandings of these staff members.
The medical service of an urban university medical centre.
The average number of documented CCCs addressed per DNR order was 1.1. The ward notes generally agreed with the perceptions of patients, house officers, and nurses (% agreement with notes = 79%, 77%, and 82%; kappa = 0.43, 0.40, 0.50). Consultant physicians' understandings were poorly reflected in the ward notes (% agreement = 59%; kappa = 0.18). They overestimated attention to CCCs compared with the notes (P < 0.0001) and with other observers (P < 0.0001).
Chart review for attention to CCCs accurately reflects the understandings of patients, house officers, and nurses, but consultant physicians report more attention to CCCs than is recorded in the ward notes or understood by other observers. Better communication regarding end-of-life care plans should be encouraged.
研究查阅病房记录（病历审查）作为衡量对下达“不要复苏”（DNR）医嘱患者护理质量指标的准确性。
我们查阅了19例连续的、有行为能力的下达DNR医嘱住院患者的病历，以寻找工作人员处理一系列广泛的患者护理需求（称为并发护理关注点，CCCs）的证据，如除复苏本身外停止治疗，以及关注患者舒适需求。然后我们对患者、会诊医生、住院医生和责任护士进行了访谈，并将病房记录与这些工作人员的认知进行了比较。
一所城市大学医疗中心的内科。
每份DNR医嘱记录的已处理CCCs平均数量为1.1。病房记录总体上与患者、住院医生和护士的认知一致（与记录的一致率分别为79%、77%和82%；kappa值分别为0.43、0.40、0.50）。会诊医生的认知在病房记录中体现不佳（一致率为59%；kappa值为0.18）。与记录相比（P<0.0001）以及与其他观察者相比（P<0.0001），他们高估了对CCCs的关注。
对CCCs关注情况的病历审查准确反映了患者、住院医生和护士的认知，但会诊医生报告的对CCCs的关注多于病房记录中所记录的或其他观察者所理解的。应鼓励就临终护理计划进行更好的沟通。
