Okkes I M, Groen A, Oskam S K, Lamberts H
Department of Family Practice, Academic Medical Center, University of Amsterdam, The Netherlands.
Methods Inf Med. 2001 Jul;40(3):229-35.
From 1985-2000, 58 Dutch family physicians (FPs) of the Transition Project collected ICPC-coded data on 47, 2451 episodes of care, first in paper records for direct encounters only, later with a complete electronic patient record (EPR) for all (direct and indirect) encounters. Based on these data, the effects of a long observation period and the inclusion of all encounters (both direct and indirect) in the EPR were studied. Long observation periods in EPRs appear to have important advantages for patient documentation and the assessment of the content of family practice. Comparison of data from a one-year versus a four-year observation period showed a shift in utilization rates. In a long observation period, visiting patients appeared to make less demand on care, while the content of the FP's care for selected chronic diseases was reflected more realistically. The inclusion of all indirect encounters in an EPR (as compared to the previous inclusion of direct encounters only) resulted in more than twice the number of coded entries per listed patient, and thus led to a major shift in perspective on the FP's involvement in patient care.
1985年至2000年期间，过渡项目的58名荷兰家庭医生收集了472451次护理事件的国际初级保健分类（ICPC）编码数据，最初仅在纸质记录中记录直接接触情况，后来使用完整的电子病历（EPR）记录所有（直接和间接）接触情况。基于这些数据，研究了长时间观察期以及在电子病历中纳入所有接触情况（直接和间接）的影响。电子病历中的长时间观察期在患者记录和家庭医疗内容评估方面似乎具有重要优势。对一年观察期和四年观察期的数据比较显示了利用率的变化。在长时间观察期内，就诊患者对护理的需求似乎减少，而家庭医生对选定慢性病的护理内容得到了更真实的反映。与之前仅纳入直接接触情况相比，在电子病历中纳入所有间接接触情况导致每个登记患者的编码条目数量增加了两倍多，从而使人们对家庭医生参与患者护理的看法发生了重大转变。
