Arshad A R, Ganesananthan S, Ajik S
Department of Plastic Surgery, Hospital Kuala Lumpur, Jalan Pahang, 50586 Kuala Lumpur.
Med J Malaysia. 2000 Sep;55(3):331-40.
A study was carried out in Kuala Lumpur Hospital to review the adequacy of documentation of bio-data and clinical data including clinical examination, progress review, discharge process and doctor's identification in ten of our clinical departments. Twenty criteria were assessed in a retrospective manner to scrutinize the contents of medical notes and subsequently two prospective evaluations were conducted to see improvement in case notes documentation. Deficiencies were revealed in all the criteria selected. However there was a statistically significant improvement in the eleven clinical data criteria in the subsequent two evaluations. Illegibility of case note entries and an excessive usage of abbreviations were noted during this audit. All clinical departments and hospitals should carry out detailed studies into the contents of their medical notes.
在吉隆坡医院开展了一项研究，以审查我们十个临床科室中生物数据和临床数据的记录完整性，包括临床检查、病情复查、出院流程以及医生身份识别。以回顾性方式评估了二十项标准，以审查病历内容，随后进行了两次前瞻性评估，以观察病历记录的改善情况。在所选定的所有标准中均发现了不足之处。然而，在随后的两次评估中，十一项临床数据标准有统计学上的显著改善。在此次审核过程中，发现病历记录字迹模糊且缩写使用过多。所有临床科室和医院都应对其病历内容进行详细研究。
