Williams Alun, Lee Patrick, Kerr Alastair
Department of Otolaryngology, Royal Hospital for Sick Children, Edinburgh, UK.
J Laryngol Otol. 2002 Jun;116(6):453-4. doi: 10.1258/0022215021911040.
Scottish Intercollegiate Guidelines Network (SIGN) guidelines on the indication for tonsillectomy in the management of sore throat were published in January 1999. To determine adherence to these guidelines in our unit, clinical records were examined on admission for tonsillectomy. Three cohorts were analysed. The first listed prior to SIGN, the second after SIGN and the third after presentation of the results of cohorts 1 and 2. The records were examined for documentation of the number of attacks of tonsillitis in the preceding year. The first cohort revealed poor documentation of attacks of tonsillitis (30 per cent). The subsequent cohorts showed progressive improvement in record keeping (74 per cent and 96 per cent). The adherence to SIGN guidelines for those with adequate documentation also improved (75 per cent, 80 per cent, 93.5 per cent). The importance of adequate record keeping to enable audit of practice and the impact of national guidelines on practice are discussed.
苏格兰校际指南网络（SIGN）关于扁桃体切除术治疗咽喉痛适应症的指南于1999年1月发布。为了确定我们科室对这些指南的遵循情况，我们检查了扁桃体切除术入院患者的临床记录。分析了三个队列。第一个队列在SIGN指南发布之前，第二个队列在SIGN指南发布之后，第三个队列在第一和第二个队列结果公布之后。检查记录以了解前一年扁桃体炎发作次数的记录情况。第一个队列显示扁桃体炎发作记录不佳（30%）。随后的队列在记录保存方面有逐步改善（74%和96%）。对于有充分记录的患者，对SIGN指南的遵循情况也有所改善（75%、80%、93.5%）。讨论了充分记录保存对于实践审计的重要性以及国家指南对实践的影响。
