目的 构建住院医师病例总结能力的评价指标,并验证其有效性。方法 本研究采用文献研究结合德尔菲法,制定住院医师病例总结能力评价指标。采用随机数字表法,选取安徽医科大学第一附属医院电子病历系统消化内科住院病历90份,3位评分者按照评价指标分别评分,采用克朗巴赫系数计算其内部一致性,类内相关系数(intraclass correlation coefficient,ICC)计算评分者之间的一致性,Spearman秩相关系数计算各条目之间相关性。结果 经过文献研究和专家咨询,明确了病例总结能力评价指标,包括临床信息准确性、适当缩小鉴别诊断、医学专业术语转化、语义限定词的使用和临床信息总结的总体评级5个条目。第二轮专家咨询问卷的克朗巴赫系数为0.823,内容效度指数0.960。该评价指标的克朗巴赫系数为0.801。各评价条目的ICC分别为0.834,0.690,0.796,0.802和0.760。医学术语转换和适当缩小鉴别诊断与临床信息总结总体评级的Spearman秩相关系数分别为0.71和0.69。结论 基于德尔菲法制定的住院医师病例总结能力评价指标具有良好的的信度和效度。评价指标具有较高的内部一致性和评分者之间一致性,各条目之间存在一定程度的相关性,其有效性在临床实践中得以初步验证。
Objective To develop a rubric to assess the ability of case summary of residents, and verify its validity. Methods In this study, the literatures combined with Delphi method were used to develop a rubric to assess the ability of case summary of residents.A total of 90 hospitalized cases of gastroenterology from the electronic medical record system in the First Affiliated Hospital of Anhui Medical University were selected by random number table method.The three raters scored according to the assessment rubric respectively. Cronbach coefficient was used to determine the internal consistency of five assessment criteria, the intraclass correlation coefficient (ICC) was used to determine the interrater agreement, and the Spearman rank correlation coefficient was used to determine the correlation among the five assessment criteria. Results After literature research and expert consultation, the assessment rubric of case summary ability was clarified,including 5 items of accuracy of clinical information, appropriate narrowing of differential diagnosis, translation of medical terms, use of semantic qualifiers, and global rating of clinical information summary.TheCronbach′s α coefficient of the second expert consultation questionnaire was 0.823 and the content validity index was 0.960.TheCronbach′s α coefficient of the assessment rubric was 0.801. The ICC of every item was 0.834, 0.690, 0.796, 0.802 and 0.760, respectively. The Spearman rank correlation coefficients for translation of medical terms and appropriate narrowing of differential diagnosis and global rating of clinical information summary are 0.71 and 0.69. Conclusions The assessment rubric of case summary ability of residents based on Delphi method has good reliability and validity. The assessment rubric has high internal consistency and inter-rater consistency.Its validation has been preliminarily verified in clinical practice.
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