O'Connor A E, Finnel L, Reid J
Thames Hospital. Alan.O'
N Z Med J. 2001 Oct 12;114(1141):443-4.
To determine if the introduction of preformatted patient record charts improved documentation by doctors in a rural emergency department.
All medical records of patients who were discharged from the emergency department were collected and analysed for a period of two weeks (control). The preformatted patient charts were then introduced for a further two weeks, and analysed for the presence or absence of key content items
After exclusions, 137 control charts and 96 preformatted charts were collected and analysed. It was found that, overall, there was a significant improvement in the number of the key items documented (p<0.005). There was a trend towards improvement in four parameters, but for three other key content items, there was a nonsignificant decline in documentation standards.
A structured proforma does improve documentation. However, the improvement is small and further studies are required before use of preformatted patient records for the undifferentiated emergency department patients can be recommended.
确定预先格式化的患者病历图表的引入是否能改善农村急诊科医生的病历记录情况。
收集并分析急诊科出院患者两周期间的所有病历（对照期）。然后引入预先格式化的患者图表，持续两周，并分析关键内容项的有无情况。
排除相关病历后，共收集并分析了137份对照图表和96份预先格式化的图表。结果发现，总体而言，记录的关键项数量有显著改善（p<0.005）。有四个参数呈改善趋势，但对于其他三个关键内容项，病历记录标准有不显著的下降。
结构化的表格确实能改善病历记录情况。然而，改善幅度较小，在推荐将预先格式化的患者病历用于未分化的急诊科患者之前，还需要进一步研究。
