J Am Med Inform Assoc - Presence of key findings in the medical record prior to a documented high-risk diagnosis.

Tópicos

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Resumo

CKGROUND: Failure or delay in diagnosis is a common preventable source of error. The authors sought to determine the frequency with which high-information clinical findings (HIFs) suggestive of a high-risk diagnosis (HRD) appear in the medical record before HRD documentation.METHODS: A knowledge base from a diagnostic decision support system was used to identify HIFs for selected HRDs: lumbar disc disease, myocardial infarction, appendicitis, and colon, breast, lung, ovarian and bladder carcinomas. Two physicians reviewed at least 20 patient records retrieved from a research patient data registry for each of these eight HRDs and for age- and gender-compatible controls. Records were searched for HIFs in visit notes that were created before the HRD was established in the electronic record and in general medical visit notes for controls.RESULTS: 25% of records reviewed (61/243) contained HIFs in notes before the HRD was established. The mean duration between HIFs first occurring in the record and time of diagnosis ranged from 19 days for breast cancer to 2 years for bladder cancer. In three of the eight HRDs, HIFs were much less likely in control patients without the HRD.CONCLUSIONS: In many records of patients with an HRD, HIFs were present before the HRD was established. Reasons for delay include non-compliance with recommended follow-up, unusual presentation of a disease, and system errors (eg, lack of laboratory follow-up). The presence of HIFs in clinical records suggests a potential role for the integration of diagnostic decision support into the clinical workflow to provide reminder alerts to improve the diagnostic focus.

Resumo Limpo

ckground failur delay diagnosi common prevent sourc error author sought determin frequenc highinform clinic find hif suggest highrisk diagnosi hrd appear medic record hrd documentationmethod knowledg base diagnost decis support system use identifi hif select hrds lumbar disc diseas myocardi infarct append colon breast lung ovarian bladder carcinoma two physician review least patient record retriev research patient data registri eight hrds age gendercompat control record search hif visit note creat hrd establish electron record general medic visit note controlsresult record review contain hif note hrd establish mean durat hif first occur record time diagnosi rang day breast cancer year bladder cancer three eight hrds hif much less like control patient without hrdconclus mani record patient hrd hif present hrd establish reason delay includ noncompli recommend followup unusu present diseas system error eg lack laboratori followup presenc hif clinic record suggest potenti role integr diagnost decis support clinic workflow provid remind alert improv diagnost focus

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