住院成人患者的哮喘管理医疗记录不足
2009/06/26
医疗档案（MR）中的患者临床信息记录不完整是向患者提供高质量医疗服务的一个障碍。最近在两个心血管相关疾病治疗研究中有报道患者病历记录不全。本文对MR中哮喘管理的病历记录进行评价，确定其是否与NIH哮喘指南相一致。我们对2004年1月～2007年5月间首次诊断为哮喘的有ICD-9疾病编码的住院患者（年龄18～49岁）进行回顾性评价。入选标准包括住院时间超过24小时，每年吸烟<10包。对药物治疗方案、哮喘相关教育记录、哮喘管理计划、转诊情况、加重因素进行评价。共分析了144名患者的233次住院病历。出院时，85％患者缺少哮喘教育相关记录，97％患者缺少书面的哮喘相关管理计划，79％未向哮喘专科转诊。呼吸道感染是与入院相关的最常见因素，58％的入院患者缺少对加重因素的记录。仅47％的患者在入院前接受了糖皮质激素吸入治疗（ICS），25％的患者在出院时未被要求在出院后继续ICS治疗。哮喘处理的相关记录不全，特别是病历中哮喘相关教育记录不足，也反应了护理上存在缺陷。此外，要求患者出院后继续进行ICS维持治疗的比例较低。
基于上述结果，有必要采取一定的措施确保病历记录的完整性，以便给患者提供更加优质的医疗服务。
基于上述结果，有必要采取一定的措施确保病历记录的完整性，以便给患者提供更加优质的医疗服务。
（陈欣 审校）
Arnold LB,et al. South Med J. 2009 Apr 15. [Epub ahead of print]
Inadequate Documentation of Asthma Management in Hospitalized Adult Patients.
Undocumented patient information in the medical record (MR) is a barrier to providing high quality care. Inadequate documentation has recently been reported for two cardiovascular diseases. This study was designed to evaluate the documentation of asthma management in the MR to determine if it is consistent with the NIH asthma guidelines. We performed a retrospective chart review of patients (ages 18-49) admitted to the hospital with an ICD-9 code for a primary diagnosis of asthma between January 2004 and May 2007. Patients admitted with a hospitalization for >24 hours and had <10 pack per year smoking history were included. We assessed medication regimens, documentation of asthma education, asthma action plans, referrals, and exacerbating factors. There were 233 admissions for 144 unique patients analyzed. At discharge, 85% of patients lacked documentation of asthma education, 97% lacked documentation of a written asthma action plan being given, and 79% did not have referral to an asthma specialist. Respiratory infection was the most common factor associated with admission; 58% of admissions were lacking documentation of the exacerbating factor. Only 47% of patients were receiving inhaled corticosteroids (ICS) prior to admission; 25% of patients did not have ICS prescribed for maintenance therapy upon discharge. Documentation of asthma management, specifically asthma education in the MR, is insufficient and may reflect a deficiency in care. Additionally, an inadequate number of patients were receiving ICS for maintenance therapy. Based on these findings, mechanisms are needed to ensure appropriate documentation and optimal care.
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使用问卷调查分析年龄、性别及疾病严重程度对支气管哮喘患者吸入性糖皮质激素选择的影响
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个体化的哮喘自我管理能改善药物治疗的依从性和哮喘控制指标
