Strauch G O
Am J Surg. 1975 Apr;129(4):401-6. doi: 10.1016/0002-9610(75)90184-1.
A system of surgical audit based on identification and solution of surgical problems is described. The system relies initially on universal review of patient records on a monthly basis by surgeons in the involved institution. Evolution of the system to one which the records of certain patients can be excluded from review by physicians is seen as practical, if careful definition of such records is maintained. Emphasis on the goal of meaningful quality of care assessment is critial. Utilizing this system, surgeons in Stamford, Connecticut, have found significant deficiencies in diagnostic, therapeutic, or both of these aspects of patient care in 5 per cent of records reviewed. Ninety-five per cent of patients were judged to have had no important inadequacies in their surgical care, based on evidence in their medical records. Attempts to evaluate surgeons' behavioral changes, when deficiencies in their patients' care have been demonstrated, are being pursued actively.
本文描述了一个基于外科问题识别与解决的手术审计系统。该系统最初依赖于相关机构的外科医生每月对患者记录进行全面审查。如果能对某些患者的记录进行仔细定义，那么将该系统演变为医生可以排除某些患者记录进行审查的系统是可行的。强调有意义的医疗质量评估目标至关重要。利用这个系统，康涅狄格州斯坦福德的外科医生在审查的5%的记录中发现患者护理的诊断、治疗或这两个方面存在重大缺陷。根据病历证据，95%的患者被判定在手术护理方面没有重大不足。当证明外科医生在患者护理方面存在缺陷时，正在积极尝试评估他们行为的变化。
