摘要
目的建立门诊癌痛专用病历质量评价方法,并对应用效果进行分析。方法运用德尔菲法制订南京医科大学附属淮安第一医院门诊癌痛专用病历质量评价标准。通过属性层次模型赋权法结合逼近理想解排序法(AHM-TOPSIS)计算各评价指标的权重,并对本院2020年6月归档的50份门诊癌痛专用病历(A组,150例次记录)书写质量进行综合评价,计算书写质量与理想解的相对接近程度(Ci值),并统计各评价指标不规范病历构成比。根据评价结果实施干预,并对干预后2021年10月归档的50份癌痛专用病历(B组,156例次记录)书写质量进行同法再评价,比较干预前后病历书写规范性及各评价指标不规范病历构成比的差异。结果建立的门诊癌痛专用病历质量评价标准包括办理专用病历所需材料完整性、疼痛相关主诉及病史记录、疼痛既往药物治疗过程的具体描述、疼痛的常规评估及记录、疼痛的量化评估及记录、疼痛的全面评估及记录、疼痛的动态评估及记录、疼痛药物选择合理性、药物用法用量合理性、合理调整药物品种或剂量、镇痛药物不良反应预防及记录、镇痛药物不良反应评价及处理记录共12项指标。干预前A组病历中,Ci≥0.6的病历占62.0%(93/150);干预后B组病历中,Ci≥0.6的病历占84.6%(132/156),差异有统计学意义(P<0.001)。干预前A组病历中,疼痛的全面评估、不良反应预防、量化评估及动态评估记录的不规范病历构成比较高,分别为64.0%(96/150)、55.3%(83/150)、54.7%(82/150)、52.7%(79/150);干预后B组病历中,上述不规范病历构成比均有所下降,分别为50.6(79/156)、35.9(56/156)、32.1(50/156)、39.7(62/156)(均P<0.05)。结论建立了基于德尔菲法及AHM-TOPSIS的门诊癌痛专用病历综合评价标准;对门诊癌痛专用病历实施综合评价及干预后,病历书写质量有所提升。
Objective To establish the quality evaluation criteria for out-patient medical records of cancer pain and evaluate the effect of its application.Methods The evaluation criterion was established based on Delphi method for out-patient medical records of cancer pain in the Affiliated Huai′an No.1 People′s Hospital of Nanjing Medical University.Firstly,the weight of each evaluation indicator was calculated by the method of Attribute Hierarchical Model in combination with technique for order preference by similarity to solution(AHM-TOPSIS),and out-patient medical records of 50 cancer pain patients(group A,150 records)received in June 2020 were assessed comprehensively.Secondly,the relative closeness(Ci value)between the writing quality and the ideal solution was calculated,as well as the proportion of evaluation indicators which were lack of standardization.Thirdly,the corresponding countermeasures were adapted based on the results of assessment.Finally,another 50 medical records(156 records)received in October 2021 were re-evaluated by the same method,and the differences of quality of medical record and proportion of each evaluation indicator which was lack of standardization before and after the intervention were compared.Results A specific criterion which contained integrity of materials required for the medical records,documents of the complaints and medical history of cancer pain,description of the previous medical treatment for cancer pain,regular assessment of cancer pain and its′document,quantitative assessment and its′document,comprehensive assessment and its′document,dynamic assessment and its′document,reasonable of pain medication,reasonable of the drug usage and dosage,reasonable adjustment of the drug variety or dosage,prevention of adverse reactions of analgesic drugs and its′document,evaluation and management of adverse reactions of analgesic drugs and its′document(12 indicators)was established to evaluate the out-patient medical records of cancer pain.The proportion of medical records which Ci≥0.6 was 62.0%(93/150)in group A before the intervention.It was increased to 84.6%(132/156)in group B after the intervention and the difference was statistically significant(P<0.001).Furthermore,the proportions of comprehensive assessment of cancer pain which were lack of standardization,prevention of adverse reaction,quantitative evaluation and dynamic assessment of cancer pain accounted for a higher level,which was 64.0%(96/150),55.3%(83/150),54.7%(93/150)and 52.7%(79/150)respectively in group A before the intervention.However,proportions of such records were decreased to 50.6%(79/156),35.9%(56/156),32.1%(50/156)and 39.7%(62/156)respectively in group B after the intervention and the differences were statistically significant(all P<0.05).Conclusions A specific quality evaluation criterion is established based on Delphi method and AHM-TOPSIS for the out-patient medical records of cancer pain.The quality of medical records has been improved in a certain level after adapting comprehensive evaluation and intervention on the out-patient medical records of cancer pain.
作者
吴晓丽
梁茂本
庄旭琴
秦海艳
秦孝峰
贾冬梅
陈佳佳
Wu Xiaoli;Liang Maoben;Zhuang Xuqin;Qin Haiyan;Qin Xiaofeng;Jia Dongmei;Chen Jiajia(Department of Pharmacy,the Affiliated Huai′an No.1 People′s Hospital of Nanjing Medical University,Huai′an 223300,China;Huai′an Third People′s Hospital,Huai′an 223301,China;Department of Outpatient,the Affiliated Huai′an No.1 People′s Hospital of Nanjing Medical University,Huai′an 223300,China;Department of Pharmacy,Huai′an Second People′s Hospital,Huai′an 223300,China)
出处
《中华医学杂志》
CAS
CSCD
北大核心
2022年第39期3115-3120,共6页
National Medical Journal of China
关键词
癌性疼痛
病历
评价方法
效果分析
干预研究
Cancerous pain
Record
Evaluation criteria
Effect analysis
Intervention study
