A comparison of problem lists generated by physicians, nurses, and patients: implications for CPR systems.
Using a sample of 201 patients hospitalized for Pneumocystis carinii pneumonia, this study describes problem lists generated by physicians and examines the overlap among problem lists generated by physicians, nurses, and patients. The findings indicate that the majority of patients in this sample had at least one problem that occurred in more than one problem list. Problems that most frequently appeared in more than one problem list were those related to the medical diagnosis of Pneumocystis carinii pneumonia and its associated physiological symptoms. Problems which occurred uniquely in the nurse problem list were knowledge deficit and potential for injury. Thirty-four percent of the patients identified at least one psychosocial problem that did not occur in either the physician- or nurse-generated problem lists. The study findings demonstrate that while there is overlap among the problem lists in problems related to the principal medical diagnoses, the nurse- and patient-generated problem lists include unique problems which provide additional significant information related to patient status that has the potential to impact patient outcomes. These findings suggest that a unified, nonredundant, multidisciplinary problem list is warranted in order to provide a comprehensive view of the patient for computer-based patient record (CPR) systems. Appropriate data models and comprehensive controlled vocabularies are needed to support the multiple uses of the problem list for CPR systems.
Henry
S B
SB
School of Nursing, University of California, San Francisco, USA.
Holzemer
W L
WL
D006801:Humans; D007297:Inpatients; D016347:Medical Records Systems, Computerized; D008501:Medical Records, Problem-Oriented; D009726:Nurses; D010820:Physicians; D011020:Pneumonia, Pneumocystis / Q000150:complications