A comparison of observed versus documented physician assessment and treatment of pain: The physician record does not reflect the reality
A comparison of observed versus documented physician assessment and treatment of pain: The physician record does not reflect the reality
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DOI：
10.1016/j.annemergmed.2008.01.004
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发表时间：
2008-10-01
影响因子：
6.2
通讯作者：
Brizendine, Edward J.
中科院分区：
文献类型：
--
作者：
Chisholm, Carey D.;Weaver, Christopher S.;Brizendine, Edward J.
研究目的：联合委员会要求对出现疼痛症状的患者进行“适当评估”。合规性通常通过回顾性图表分析来评估。我们调查观察到的医生疼痛评估和随后记录在医疗记录之间的差异。方法：这是一项观察性研究，由一名训练有素的调查员观察急诊医生的床边互动。使用先验定义，研究者记录了患者是否主动提出疼痛，医生是否询问疼痛，是否尝试量化疼痛，是否接受了治疗。以及对治疗反应的评估。随后，一名独立调查员评估了患者的疼痛评估、治疗和治疗反应的病历。年龄小于5岁的儿童和有严重创伤、精神状态改变或非创伤性胸痛的患者被排除在外。机构审查委员会批准了该方案，医生同意在不知道数据收集的确切性质的情况下参与一项“人体工程学研究”，患者也公布了他们的记录。结果：研究者观察了209例患者。医生在98.1%的时间里承认了患者的疼痛，但在91.7%的时间里记录了疼痛的存在。61.5%的医生试图量化病人的疼痛，但只有38.9%的医生记录了这种尝试。79.9%的患者接受了治疗，31.7%的患者有病历记录。当提供治疗时，患者对治疗的反应只有28%的时间被记录下来。结论：医生几乎总是评估和治疗病人的疼痛，但很少记录这些努力。病人的图表是一个很差的替代标记疼痛评估和护理的急诊医生，可能不适合使用作为依从性评估工具。采用回顾性图表分析的研究方法可能会受到这种现象的影响，这表明急诊医生可能低估了患者疼痛评估和治疗。
Study objective: The Joint Commission requires "appropriate assessment" of patients presenting with painful conditions. Compliance is usually assessed through retrospective chart analysis. We investigate the discrepancy between observed physician pain assessment and that subsequently documented in the medical record.Methods: This was an observational study using a trained investigator watching bedside interactions of emergency physicians. Using a priori definitions, the investigator recorded whether the patient volunteered the presence of pain, physician inquiry about pain, attempts to quantify the pain, treatment offered/rendered. and any assessment of the response to therapy. An independent investigator subsequently assessed the patient's chart for documentation of pain assessment, therapy rendered, and response to treatment. Children younger than 5 years and patients with major trauma, altered mental status, or nontraumatic chest pain were excluded. The institutional review board approved the protocol, the physicians agreed to participate in an "ergonomic study" without knowing the exact nature of data collection, and patients released their records.Results: The investigator observed 209 patient encounters. Physicians acknowledged the patients' pain 98.1% of the time but documented its presence in 91.7%. Physicians attempted to quantify the patient's pain in 61.5% of encounters but documented that attempt in only 38.9%. Treatment was offered in 79.9% and recorded in 31.7% of charts. When treatment was offered, the patient's response to the therapy was recorded only 28% of the time.Conclusion: Physicians almost always assess and treat patient pain but infrequently record those efforts. The patient's chart is a poor surrogate marker for pain assessment and care by emergency physicians and may not be suitable for use as a compliance assessment tool. Research methodology using retrospective chart analysis may be affected by this phenomenon, suggesting the potential for underestimation of patient pain assessment and treatment by emergency physicians.