Russo R M, Gururaj V J, Laude T A, Rajkumar S V, Ventre S A
Pediatrics. 1975 Aug;56(2):246-54.
A system of providing rapid review of ambulatory patient records using a set of criteria was developed and tested. Of 337 records selected for review, 25% were not reviewable. Of the remaining 75%, virtually one half proved to be lacking in one or more of the established criteria. Deficiencies tended to occur most often in criteria related to the physical examination of the child. Physician compliance with the criteria could not be conclusively shown to improve during the five-month study period, although physician acceptability was judged as good. A large percentage (47.3%) of deficient records could be corrected by the responsible health professional. The chief advantages of the system are that it is rapid and easy to perform. It focuses on the major service provided by the facility, i.e., acute medical care, and on the performance of the individual providing that service.
开发并测试了一种使用一套标准对门诊患者记录进行快速审查的系统。在选取用于审查的337份记录中，25%无法审查。在其余75%的记录中，实际上有一半被证明在一项或多项既定标准方面存在欠缺。不足之处往往最常出现在与儿童体格检查相关的标准中。尽管医生对该标准的接受度被判定良好，但在为期五个月的研究期间，无法确凿地表明医生对标准的遵守情况有所改善。很大比例（47.3%）的有缺陷记录可由负责的卫生专业人员纠正。该系统的主要优点是快速且易于操作。它关注设施提供的主要服务，即急性医疗护理，以及提供该服务的个人的表现。
