Zuckerman Z E, Starfield B, Hochreiter C, Kovasznay B
Pediatrics. 1975 Sep;56(3):407-11.
Information in 51 tape-recorded physician-patient encounters was compared with information written in the patients' medical records. Diagnoses, chief complaints, scheduled appointments, non-drug therapy, and diagnostic studies were uniformly well-recorded. Medication names were well-recorded but dosages were not. Characteristics of care such as levels of function, probable cause of illness, reason for follow-up, and compliance were recorded poorly. Patients were more likely to known about and understand their diagnosis, and names, dosage, and intended function of their medications when this information was written in the record than when it was not. These findings indicate a relationship between the quality of medical records and the effectiveness of care.
对51次医患面谈的录音信息与患者病历中所写信息进行了比较。诊断结果、主要症状、预约安排、非药物治疗及诊断检查均记录良好。药物名称记录良好，但剂量记录不佳。功能水平、可能病因、随访原因及依从性等护理特征记录较差。当这些信息记录在病历中时，患者比未记录时更有可能了解并理解自己的诊断以及所用药物的名称、剂量和预期作用。这些发现表明病历质量与护理效果之间存在关联。
