儿科医院病历:质量评估。

Australian clinical review Pub Date : 1992-01-01
K P Dawson, N Capaldi, M Haydon, A C Penna
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引用次数: 0

摘要

本研究的目的是评估在儿童部门病历的医疗贡献的质量。实验在某三级教学医院进行。对随机选择的100例病例记录进行结构化审计,由独立观察员对其中3项措施采用分级系统。结果提供了一个比较与医院的指导方针的病史和笔记。这项研究的结果表明,基本信息的文件记录不足。糟糕的书写和使用缩写阻碍了交流。对病人病程的全面了解被认为是中等水平。超过70%的病历记录有诊断和初步治疗计划。虽然出院信息得到了很好的记录,但对药物治疗持续时间的建议是不充分的。医疗记录中仍然普遍存在字迹平庸和文件不完善的情况。对这一重要医疗实践领域的严格监督是强制性的。
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The paediatric hospital medical record: a quality assessment.

The objective of this study was to assess the quality of the medical contribution to patient records in a children's department. It was carried out in a tertiary level teaching hospital. A structured audit of 100 randomly selected case records, with independent observers using a grading system for 3 of the measures, was performed. The outcome provides a comparison with the hospital's guidelines for case histories and notes. The results of this study show inadequate documentation of basic information. Communication was hindered by poor hand writing and the use of abbreviations. Overall comprehension of the course of the patients' illnesses was regarded as only fair to average. Recording of diagnosis and initial plans of management were present in over 70% of records. While discharge information was well recorded, the recommendation for the duration of drug therapy was inadequate. Mediocre handwriting and poor documentation are still prevalent in medical records. Strict supervision of this important area of medical practice is mandatory.

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