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首页> 外文期刊>Implementation Science >Peer chart audits: A tool to meet Accreditation Council on Graduate Medical Education (ACGME) competency in practice-based learning and improvement
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Peer chart audits: A tool to meet Accreditation Council on Graduate Medical Education (ACGME) competency in practice-based learning and improvement

机译：对等图审核：满足研究生医学教育认证委员会（ACGME）在基于实践的学习和改进中的能力的工具

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Background The Accreditation Council on Graduate Medical Education (ACGME) supports chart audit as a method to track competency in Practice-Based Learning and Improvement. We examined whether peer chart audits performed by internal medicine residents were associated with improved documentation of foot care in patients with diabetes mellitus. Methods A retrospective electronic chart review was performed on 347 patients with diabetes mellitus cared for by internal medicine residents in a university-based continuity clinic from May 2003 to September 2004. Residents abstracted information pertaining to documentation of foot examinations (neurological, vascular, and skin) from the charts of patients followed by their physician peers. No formal feedback or education was provided. Results Significant improvement in the documentation of foot exams was observed over the course of the study. The percentage of patients receiving neurological, vascular, and skin exams increased by 20% (from 13% to 33%) (p = 0.001), 26% (from 45% to 71%) (p < 0.001), and 18% (51%–72%) (p = 0.005), respectively. Similarly, the proportion of patients receiving a well-documented exam which includes all three components – neurological, vascular and skin foot exam – increased over time (6% to 24%, p < 0.001). Conclusion Peer chart audits performed by residents in the absence of formal feedback were associated with improved documentation of the foot exam in patients with diabetes mellitus. Although this study suggests that peer chart audits may be an effective tool to improve practice-based learning and documentation of foot care in diabetic patients, evaluating the actual performance of clinical care was beyond the scope of this study and would be better addressed by a randomized controlled trial.
机译：背景研究生医学教育认证委员会（ACGME）支持将图表审计作为一种方法来跟踪基于实践的学习和改进中的能力。我们检查了内科住院医师进行的同伴图表审核是否与糖尿病患者足部护理的文献记载有所改善。方法2003年5月至2004年9月，在一家大学的连续性诊所对347例由内科住院医师照顾的糖尿病患者进行了回顾性电子图表审查。居民提取了与足部检查记录（神经，血管和皮肤）有关的信息），从患者图表中跟随他们的医师同行。没有提供正式的反馈或教育。结果在整个研究过程中，观察到了足部检查记录的显着改善。接受神经，血管和皮肤检查的患者百分比分别增加了20％（从13％增至33％）（p = 0.001），26％（从45％增至71％）（p <0.001）和18％（ 51％–72％）（p = 0.005）。同样，接受完备记录的包括神经，血管和皮肤足部检查这三个组成部分的检查的患者比例也随时间增加（6％到24％，p <0.001）。结论居民在没有正式反馈的情况下进行的对等图表审计与糖尿病患者足部检查的文献记录改善有关。尽管这项研究表明同伴图表审核可能是改善基于实践的学习和糖尿病患者足部护理记录的有效工具，但是评估临床护理的实际表现超出了本研究的范围，可以通过随机分配更好地解决对照试验。

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