Grant Penny, Skinner Halcyon G, Fleming Lora E, Bean Judy A
Department of Pediatrics, University of Miami School of Medicine, Fla, USA.
South Med J. 2002 Sep;95(9):1026-31.
Age-specific structured encounter forms for well-child examinations have been shown to improve thoroughness of documentation among pediatric house staff. This study evaluated the influence of such forms on completeness of documentation by practicing pediatricians.
In this before-after trial at 5 urban community health clinics, participants were 8 pediatricians practicing for at least 1 year. Brief group training sessions on use of the forms were provided to the participating physicians. Completeness of documentation was defined as the proportion of elements from a full well-child examination recorded in the medical record.
After introduction of the standardized forms, completeness of documentation significantly increased for all components.
The use of age-specific structured encounter forms improved the completeness of documentation of pediatric well-child examinations done by pediatricians.
针对儿童健康检查的特定年龄结构化问诊表格已被证明可提高儿科住院医师记录的完整性。本研究评估了此类表格对执业儿科医生记录完整性的影响。
在5家城市社区卫生诊所进行的这项前后对照试验中，参与者为8名从业至少1年的儿科医生。为参与的医生提供了关于表格使用的简短小组培训课程。记录完整性定义为完整儿童健康检查中各项内容在病历中的记录比例。
引入标准化表格后，所有组成部分的记录完整性均显著提高。
使用特定年龄的结构化问诊表格提高了儿科医生进行的儿童健康检查记录的完整性。
