Goodyear H M, Lloyd B W
North Middlesex Hospital, London, England.
Qual Health Care. 1995 Sep;4(3):190-3. doi: 10.1136/qshc.4.3.190.
Inpatient medical notes often fail to record important details of patient history and findings on clinical examination. To overcome problems with content and legibility of notes we introduced preprinted notes for the admission of children to this hospital. The quality of the information recorded for 100 children whose admissions were clerked with the preprinted notes was compared with that recorded for 100 whose admissions were recorded with the traditional notes. All case notes were selected randomly and retrospectively from traditional notes written from April to October 1993 and from preprinted notes written from October 1993 to April 1994. The quality of information was assessed according to the presence or absence of 25 agreed core clinical details and the number of words per clerking. In admissions recorded with the preprinted notes the mean number of core clinical details present was significantly higher than those recorded with traditional notes (24.0 v 17.6, p < 0.00001). Admissions recorded with the preprinted notes were also significantly shorter (mean 144 words v 184 words, p < 0.0001). The authors conclude that information about children admitted to hospital is both more complete and more succinct when recorded using preprinted admission sheets.
住院病历往往未能记录患者病史的重要细节以及临床检查结果。为克服病历内容和可读性方面的问题，我们为本医院儿童入院引入了预印病历。将使用预印病历收治的100名儿童的记录信息质量，与使用传统病历收治的100名儿童的记录信息质量进行了比较。所有病例记录均从1993年4月至10月书写的传统病历以及1993年10月至1994年4月书写的预印病历中随机选取并进行回顾性分析。根据25项商定的核心临床细节的有无以及每份病历的字数来评估信息质量。使用预印病历记录的入院病例中，存在的核心临床细节平均数量显著高于使用传统病历记录的病例（24.0对17.6，p<0.00001）。使用预印病历记录的入院病例也明显更简短（平均144字对184字，p<0.0001）。作者得出结论，使用预印入院单记录时，入院儿童的信息更完整且更简洁。
