Robins A, Gallagher A, Rossiter M A, Lloyd B W
North Middlesex Hospital, London, UK.
Qual Health Care. 1997 Dec;6(4):192-3. doi: 10.1136/qshc.6.4.192.
To determine the views of doctors and nurses about two recent innovations in the structure of case notes: the use of preprinted prompts and the use of joint medical and nursing notes.
Questionnaire survey of all doctors and nurses working on the children's wards.
Children's wards in a district general hospital.
Whether or not respondents wanted to return to traditional notes; positive and negative aspects of the two innovations.
There was an 81% response rate. 45 of 48 respondents (94%) did not want to return to traditional notes. Positive features of joint notes that were identified included: promotes team work (21/48 respondents), improves access to information (14/48), and reduces duplication (14/48). Negative features included uncertainty about identity of writer (8/48) and incompletely filled in sheets (7/48). Positive features of preprinted prompts included: less information omitted (29/48), easier to read and find information (28/48), and quicker to write (21/48). Negative features included: not enough space (19/48) and clerking too mechanical (16/48).
Advantages of both innovations outweighed their disadvantages to the extent that only three out of 48 respondents wanted to return to writing traditional notes.
确定医生和护士对病历结构方面两项近期创新举措的看法，即使用预先印制的提示信息以及采用医护联合病历。
对在儿科病房工作的所有医生和护士进行问卷调查。
一家地区综合医院的儿科病房。
受访者是否希望恢复使用传统病历；两项创新举措的积极和消极方面。
回复率为81%。48名受访者中有45名（94%）不希望恢复使用传统病历。联合病历的积极特征包括：促进团队合作（21/48名受访者）、改善信息获取（14/48）以及减少重复（14/48）。消极特征包括记录者身份不确定（8/48）以及表格填写不完整（7/48）。预先印制提示信息的积极特征包括：遗漏信息较少（29/48）、信息更易于阅读和查找（28/48）以及书写更快（21/48）。消极特征包括：空间不足（19/48）以及书写病历过于机械（16/48）。
两项创新举措的优点超过了缺点，以至于48名受访者中只有3人希望恢复书写传统病历。
