Dresselhaus T R, Luck J, Peabody J W
Veterans Affairs San Diego Healthcare System, University of San Diego, California, USA.
J Med Ethics. 2002 Oct;28(5):291-4. doi: 10.1136/jme.28.5.291.
To determine if the medical record might overestimate the quality of care through false, and potentially unethical, documentation by physicians.
Prospective trial comparing two methods for measuring the quality of care for four common outpatient conditions: (1) structured reports by standardised patients (SPs) who presented unannounced to the physicians' clinics, and (2) abstraction of the medical records generated during these visits.
The general medicine clinics of two veterans affairs medical centres.
Twenty randomly selected physicians (10 at each site) from among eligible second and third year internal medicine residents and attending physicians.
Explicit criteria were used to score the medical records of physicians and the reports of SPs generated during 160 visits (8 cases x 20 physicians). Individual scoring items were categorised into four domains of clinical performance: history, physical examination, treatment, and diagnosis. To determine the false positive rate, physician entries were classified as false positive (documented in the record but not reported by the SP), false negative, true positive, and true negative.
False positives were identified in the medical record for 6.4% of measured items. The false positive rate was higher for physical examination (0.330) and diagnosis (0.304) than for history (0.166) and treatment (0.082). For individual physician subjects, the false positive rate ranged from 0.098 to 0.397.
These data indicate that the medical record falsely overestimates the quality of important dimensions of care such as the physical examination. Though it is doubtful that most subjects in our study participated in regular, intentional falsification, we cannot exclude the possibility that false positives were in some instances intentional, and therefore fraudulent, misrepresentations. Further research is needed to explore the questions raised but incompletely answered by this research.
确定病历是否可能因医生虚假且可能不道德的记录而高估医疗质量。
前瞻性试验，比较两种测量四种常见门诊疾病医疗质量的方法：（1）由未提前预约就前往医生诊所的标准化患者（SP）提供的结构化报告，以及（2）对这些就诊期间生成的病历进行摘要分析。
两家退伍军人事务医疗中心的普通内科诊所。
从符合条件的二年级和三年级内科住院医师及主治医师中随机挑选20名医生（每个地点10名）。
使用明确的标准对医生的病历以及160次就诊（8个病例×20名医生）期间SP生成的报告进行评分。各个评分项目被归类为临床绩效的四个领域：病史、体格检查、治疗和诊断。为确定假阳性率，将医生记录分为假阳性（记录中有但SP未报告）、假阴性、真阳性和真阴性。
在病历中，6.4%的测量项目被确定为假阳性。体格检查（0.330）和诊断（0.304）的假阳性率高于病史（0.166）和治疗（0.082）。对于个体医生受试者，假阳性率范围为0.098至0.397。
这些数据表明，病历错误地高估了诸如体格检查等重要医疗维度的质量。虽然我们研究中的大多数受试者不太可能经常故意造假，但我们不能排除假阳性在某些情况下是故意的，因此是欺诈性陈述的可能性。需要进一步研究来探讨本研究提出但未完全解答的问题。
