术后并发症的记录:数量和质量。

Pierre Maina, Mads Carstensen, Hanne Tønnesen
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引用次数: 6

摘要

目的:探讨一种简便的记录术后并发症的工作方法。设计:前瞻性队列研究。环境:丹麦教学医院。对象:1996年3月~ 7月手术的312例患者中218例。干预措施:手术后30天,通过查阅当地并发症登记册、审查医疗记录和对患者进行有组织的电话访谈进行随访。主要结局指标:发病率。结果:所有患者均在当地登记,并发症发生率为21% (n = 49)。然而,病历和电话访谈显示并发症发生率分别为68例(31%)和76例(33%)。结论:通过简化工作程序可以提高记录的数量,但记录的质量仍是一个挑战。
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Recording of postoperative complications: quantity and quality.

Objective: To evaluate a simple working procedure for recording postoperative complications.

Design: Prospective cohort study.

Setting: Teaching hospital, Denmark.

Subjects: 218 of 312 patients who were operated on from March to July 1996.

Interventions: Follow up 30 days after operation by looking up the local register of complications, review of medical records and by structured telephone interview with the patient.

Main outcome measures: Morbidity.

Results: All the patients were recorded in the local register, showing a complication rate of 21% (n = 49). However the medical record and the telephone interview showed complication rates of 68 (31%) and 76 (33%), respectively.

Conclusion: It is possible to improve the quantity of the recording by a simplified working procedure, while the quality is still a challenge.

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