■在医疗环境中,高质量的文档对于提供安全的患者护理至关重要。这项研究的目的是评估抗凝诊所的病历标准,并调查药剂师和医生撰写的笔记之间的区别。
对2020年10月至12月在抗凝诊所接受抗凝治疗的患者进行了电子健康记录(EHR)数据的回顾性横断面分析。在两个抗凝诊所监测患者,一个由药剂师管理,另一个由医生管理。文件的质量是用分数来评估的,并根据其得分将该笔记分配为五个类别之一:非常好,不错,平均,可怜的,而且很穷.使用Stata/SE13.1分析数据。在所有分析测试中P值<0.05被认为是显著的。
■共纳入331例患者。虽然160名患者(48.3%)被医生主导的诊所跟踪,171(51.6%)由药剂师领导的诊所。患者的平均年龄为54±15。60.73%是女性,其中90.3%是沙特国民。华法林是使用最广泛的抗凝剂(70%),其次是利伐沙班(15.7%)。与医生相比,药剂师表现出非常强的文件(54%与18%)。对研究中考虑的变量的检查显示,医生的药物-药物相互作用文件明显较少(17vs.71倍)或药物-食品相互作用文件(23vs.71倍)比药剂师。就随访频率而言,发现药剂师遵守临床方案的频率(150倍)高于医师(104倍).然而,两组间的治疗计划记录无显著差异.(p=0.416)。
■药剂师的文档比抗凝诊所的医生更全面。统一的临床文档可以确保所有学科的EHR中的文档一致。
UNASSIGNED: High-quality documentation is critical in medical settings for providing safe patient care. This study was done with the objective of assessing the standard of medical records in anticoagulation clinics and investigating the distinctions between notes written by pharmacists and physicians.
UNASSIGNED: A retrospective cross-sectional analysis of data from electronic health records (EHRs) was performed on patients who received anticoagulation and were observed at anticoagulation clinics from October to December 2020. Patients were monitored in two anticoagulation clinics, one administered by pharmacists and the other by physicians. The quality of the documentation was assessed using a score, and the note was assigned one of five categories according to its score: very good, good, average, poor, and very poor. The data was analyzed using Stata/SE 13.1. P value<0.05 was considered significant in all analytical tests.
UNASSIGNED: A total of 331 patients were included. While 160 patients (48.3%) were followed by the physician-led clinic, 171 (51.6%) were by the pharmacist-led clinic. The average age of the patients was 54 ± 15. 60.73% of them were female, and 90.3% of them were Saudi nationals. Warfarin was the most widely used anticoagulant (70%), followed by rivaroxaban (15.7%). Compared to physicians, pharmacists demonstrated very strong documentation (54% vs. 18%). The examination of the variables considered in the study revealed that physicians had significantly less drug-drug interaction documentation (17 vs. 71 times) or drug-food interaction documentation (23 vs. 71 times) than pharmacists. In terms of follow-up frequency, pharmacists were found to adhere to the clinic protocol (150 times) more frequently than physicians (104 times). However, there was no significant difference in therapeutic plan documentation between the two groups. (p = 0.416).
UNASSIGNED: Pharmacists were more comprehensive in their documentation than physicians in anticoagulation clinics. Unified clinic documentation can ensure consistent documentation within EHRs across all disciplines.