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Abstract：
Little is known about documentation during transitions of patient care between clinical specialties. Therefore, we examined the focus, structure and purpose of physician progress notes for patients transferred from the intensive care unit (ICU) to hospital ward to identify opportunities to improve communication breaks.
This was a prospective cohort study in ten Canadian hospitals. We analyzed physician progress notes for consenting adult patients transferred from a medical-surgical ICU to hospital ward. The number, length, legibility and content of notes was counted and compared across care settings using mixed-effects linear regression models accounting for clustering within hospitals. Qualitative content analyses were conducted on a stratified random sample of 32 patients.
A total of 447 patient medical records that included 7052 progress notes (mean 2.1 notes/patient/day 95% CI 1.9-2.3) were analyzed. Notes written by the ICU team were significantly longer than notes written by the ward team (mean lines of text 21 vs. 15, p < 0.001). There was a discrepancy between documentation of patient issues in the last ICU and first ward notes; mean agreement of patient issues was 42% [95% CI 31-53%]. Qualitative analyses identified eight themes related to focus (central point - e.g., problem list), structure (organization, - e.g., note-taking style), and purpose (intention - e.g., documentation of patient course) of the notes that varied across clinical specialties and physician seniority.
Important gaps and variations in written documentation during transitions of patient care between ICU and hospital ward physicians are common, and include discrepancies in documentation of patient information.
This was a prospective cohort study in ten Canadian hospitals. We analyzed physician progress notes for consenting adult patients transferred from a medical-surgical ICU to hospital ward. The number, length, legibility and content of notes was counted and compared across care settings using mixed-effects linear regression models accounting for clustering within hospitals. Qualitative content analyses were conducted on a stratified random sample of 32 patients.
A total of 447 patient medical records that included 7052 progress notes (mean 2.1 notes/patient/day 95% CI 1.9-2.3) were analyzed. Notes written by the ICU team were significantly longer than notes written by the ward team (mean lines of text 21 vs. 15, p < 0.001). There was a discrepancy between documentation of patient issues in the last ICU and first ward notes; mean agreement of patient issues was 42% [95% CI 31-53%]. Qualitative analyses identified eight themes related to focus (central point - e.g., problem list), structure (organization, - e.g., note-taking style), and purpose (intention - e.g., documentation of patient course) of the notes that varied across clinical specialties and physician seniority.
Important gaps and variations in written documentation during transitions of patient care between ICU and hospital ward physicians are common, and include discrepancies in documentation of patient information.
摘要：
关于临床专科之间患者护理过渡期间的文档知之甚少。因此,我们检查了焦点，从重症监护病房（ICU）转移到医院病房的患者的医师进度记录的结构和目的，以确定改善沟通中断的机会。
这是加拿大10家医院的前瞻性队列研究。我们分析了同意从医疗外科ICU转移到医院病房的成年患者的医生进度记录。数字,长度,使用考虑医院内部聚类的混合效应线性回归模型,计算和比较了不同护理环境中注释的可读性和内容.对32例患者的分层随机样本进行了定性内容分析。
共分析了447份患者医疗记录，其中包括7052份进展记录（平均2.1个记录/患者/天，95%CI1.9-2.3）。ICU团队撰写的笔记明显长于病房团队撰写的笔记（平均文本行21与15，p<0.001）。最后一个ICU的患者问题记录与第一病房记录之间存在差异；患者问题的平均一致性为42％[95％CI31-53％]。定性分析确定了与焦点相关的八个主题(中心点-例如，问题列表)，结构(组织，-e.g.,笔记风格)，和目的(意图-例如，患者课程的文档）的注释因临床专业和医师资历而异。
在ICU和医院病房医生之间的患者护理过渡期间，书面文件中的重要差距和变化是常见的，并包括患者信息文档中的差异。
这是加拿大10家医院的前瞻性队列研究。我们分析了同意从医疗外科ICU转移到医院病房的成年患者的医生进度记录。数字,长度,使用考虑医院内部聚类的混合效应线性回归模型,计算和比较了不同护理环境中注释的可读性和内容.对32例患者的分层随机样本进行了定性内容分析。
共分析了447份患者医疗记录，其中包括7052份进展记录（平均2.1个记录/患者/天，95%CI1.9-2.3）。ICU团队撰写的笔记明显长于病房团队撰写的笔记（平均文本行21与15，p<0.001）。最后一个ICU的患者问题记录与第一病房记录之间存在差异；患者问题的平均一致性为42％[95％CI31-53％]。定性分析确定了与焦点相关的八个主题(中心点-例如，问题列表)，结构(组织，-e.g.,笔记风格)，和目的(意图-例如，患者课程的文档）的注释因临床专业和医师资历而异。
在ICU和医院病房医生之间的患者护理过渡期间，书面文件中的重要差距和变化是常见的，并包括患者信息文档中的差异。
