Zhongguo cuzhong zazhi (May 2023)
卒中患者病历出院小结现状及其与住院医师规范化培训的相关性研究 Study on Discharge Summary Quality Analysis of Stroke Patients and Its’ Association with Standardized Training for Resident Doctors
Abstract
目的 调查卒中患者病历出院小结现状，以及住院医师规范化培训与出院小结的关系，梳理目前存在的问题，为下一步制定针对性改善措施提供可靠数据。 方法 本研究通过调查一个区域性高级卒中中心连续2个月出院卒中患者病历的出院小结，利用标准病历书写质量（针对书写内容重要元素完整性及质量等7项内容，总分10分）及卒中病历质量评分（包括卒中类型、病因分型、诊疗经过及用药、并发症描述、出院时神经功能评估、预后评估、进一步诊断检查建议、出院用药指导、出院血压及血脂控制目标及治疗随访建议11个项目，每项目计1分，共计11分）对其进行定量评估，了解其现状，总结存在的问题，并比较经过神经专科一阶段培训和未经过培训的住院医师在书写出院小结中暴露的问题差异。 结果 共收集卒中患者病历出院小结105份，分别来自6位不同年资的住院医师。标准病历书写质量总体得分为6～10分，平均得分为（9±1）分，＞8分比例为83.8%（88/105），最低分为6分（1份）。主要不达标部分在出院医嘱中关于复诊时间及复查项目方面，比例为50.5%（53/105）。卒中病历质量总体得分为4～10分，平均分为（7±1）分，≥7分比例为76.2%（80/105），不达标比例项最高在血压、血脂控制目标部分，达标比例分别只有6.7%（7/105）和1.0%（1/105）。经过神经专科一阶段培训的高年资住院医师组和未经过培训的低年资住院医师组标准病历书写质量得分均为（9±1）分（P=0.753），各子项得分差异也无统计学意义（P均＞0.05）；两组卒中病历质量评分均为（7±1）分（P=0.335），但在卒中病历质量评分的子项中关于进一步诊疗计划方面，高年资住院医师组书写质量达标比例较低年资住院医师组稍高（95.6% vs. 78.4%，P=0.016）。 结论 卒中患者病历出院小结书写质量整体尚可，但具体危险因素控制指标及进一步诊疗随访计划等书写质量还有待于进一步提高。住院医师培养方面，在住院医师专科培训中要突出卒中病历内涵书写的重要性。 Abstract: Objective To investigate the current situation of discharge summary of stroke patients, as well as the relationship between standardized training of resident doctors and discharge summary, to clarify the existing problems, and to provide reliable data for formulating targeted improvement measures in the next step. Methods This study examined the discharge summary of the medical records of stroke patients discharged during the continuous 2 months from a regional advanced stroke center. The criteria for case quality scales (including 7 items about integrity and quality of important elements of writing content, 10 points in total) and stroke medical record quality scores (including stroke type, etiology classification, diagnosis and treatment process and medication, complication description, neurological function evaluation at discharge, prognosis evaluation, further diagnosis and examination suggestions, discharge medication guidance, discharge blood pressure and lipid control objectives and treatment follow-up suggestions, 1 points for each item, 11 points in total) were used to evaluate the cases we collected by two stroke neurologists independently. To understand the current situation, summarize the existing problems, and compare the differences between residents who were before and after neurology first-stage training. Results A total of 105 cases were included into analysis, which were written by 6 residents at different levels. The overall score for standard medical record writing quality ranged from 6-10, and the average score was 9±1. Most of them were above 8 points (83.8%, 88/105) . One case got the lowest score of 6 points. 50.5% (53/105) of them have some defect on suggestions after discharge, as well as follow up time. The overall score for stroke medical history quality score ranged from 4-10, and the average score was 7±1. 76.2% (80/105) were 7 points and above. Of the items included, treatment goals for blood pressure and lipid ranking last, only 6.7% (7/105) and 1.0% (1/105) reached the standard, individually. The scores of standard medical record writing quality of senior residents who had received first-stage training in neurology and those of junior residents who had not received training were (9±1) points (P=0.753) , and there was no significant difference in the scores of each sub-item (P > 0.05) . The quality scores of stroke patients medical records in both groups were (7±1) points (P=0.335) . However, in terms of the stroke patients medical records quality score for further diagnostic, the writing quality of the senior residents was slightly higher than junior residents (95.6% vs. 78.4%, P=0.016) . Conclusions The general stroke case discharge summary is acceptable, but need further improvement in content, especially for the treatment goals in cardiovascular risk factors, as well as in further follow up. In terms of residency training, the importance of writing stroke medical records should be highlighted in the residency training in the future.
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