Stausberg J
Institute for Medical Informatics, Biometry and Epidemiology, Medical Faculty, University of Essen, Germany.
Stud Health Technol Inform. 1997;43 Pt B:864-8.
A retrospective study about the impact of different quality control methods for medical documentation was performed at the Surgical Center II in Essen. The standardized medical documentation was legislative obliged since the first of 1996 and includes diagnoses and surgical procedures. The patient data were taken from the computer-based patient record of the Surgical Center II which is in routine use since 1989. Quality improvement was aimed at with lectures, training, a quality circle, and systematic approaches like feedback and reminder between 1995 and 1996. The results demonstrate that information and training of physicians is significantly less important for the quality of documentation than a departmental and central control. It is advisable to take this results into account introducing new documentation entities and procedures and to provide functionalities for a periodical control soon.
在埃森的第二外科中心开展了一项关于不同医疗文件质量控制方法影响的回顾性研究。自1996年1月起，标准化医疗文件成为法定要求，内容包括诊断和外科手术。患者数据取自第二外科中心自1989年起常规使用的基于计算机的患者记录。在1995年至1996年期间，通过讲座、培训、质量圈以及反馈和提醒等系统方法来实现质量改进。结果表明，对于文件质量而言，医生的信息和培训远不如部门和中心控制重要。在引入新的文件实体和程序时，考虑到这一结果并尽快提供定期控制功能是明智的。
