Duback U C, Schütz R
Schweiz Med Wochenschr. 1975 May 31;105(22):698-704.
100 medical records of male and female patients seen for the first time in 1972 at the Medical Outpatients Department, University of Basel (Switzerland) were reviewed retrospectively to assess the quality of history and clinical as well as laboratory diagnostic procedures. In addition, 10 patients were selected for total re-evaluation by renewal clinical and laboratory examinations. On the basis of entries made in the medical records (format DIN A5) the medical history and the clinical examination were judged to be of good quality. A minimal program for laboratory investigation (sedimentation rate, hemoglobin, leukocyte count, serum-transaminase, BUN, urine for sugar and albumin and urine sediment) and small format chest-X-ray had been carried out according to the rules and supplement by additional investigations in 87%. The retrospective check on 10 patients showed that the first examination had been well done and without omissions. Continuous checking of diagnostic procedures was recognized as important, and changes in the forms used were admitted to be necessary for improving quality.
回顾性地查阅了1972年首次就诊于瑞士巴塞尔大学门诊部的100例男女患者的病历，以评估病史质量、临床及实验室诊断程序。此外，挑选了10例患者通过重新进行临床和实验室检查进行全面重新评估。根据病历记录（A5格式），病史和临床检查质量良好。按照规定进行了实验室检查的基本项目（血沉、血红蛋白、白细胞计数、血清转氨酶、尿素氮、尿糖、尿白蛋白及尿沉渣检查），87%的患者还根据需要进行了补充检查，并拍摄了小格式胸部X光片。对10例患者的回顾性检查显示首次检查做得很好，没有遗漏。持续检查诊断程序被认为很重要，承认有必要对使用的表格进行更改以提高质量。
