Heard S R, Roberts C, Furrows S J, Kelsey M, Southgate L
London Deanery, 20 Guilford Street, London, WC1N 1DZ, UK.
J Clin Pathol. 2003 Jan;56(1):43-7. doi: 10.1136/jcp.56.1.43.
The performance procedures of the General Medical Council are aimed at identifying seriously deficient performance in a doctor. The performance procedures require the medical record to be of a standard that enables the next doctor seeing the patient to give adequate care based on the available information. Setting standards for microbiological record keeping has proved difficult. Over one fifth of practising medical microbiologists (including virologists) in the UK (139 of 676) responded to a survey undertaken by the working group developing the performance procedures for microbiology, to identify current practice and to develop recommendations for agreement within the profession about the standards of the microbiological record. The cumulative frequency for the surveyed recording methods used indicated that at various times 65% (90 of 139) of respondents used a daybook, 62% (86 of 139) used the back of the clinical request card, 57% (79 of 139) used a computer record, and 22% (30 of 139) used an index card system to record microbiological advice, suggesting wide variability in relation to how medical microbiologists maintain clinical records.
英国医学总会的执业程序旨在识别医生严重不足的执业表现。这些执业程序要求病历达到一定标准,以便下一位诊治该患者的医生能够根据现有信息提供充分的护理。事实证明,为微生物学记录设定标准颇具难度。英国超过五分之一的在职医学微生物学家(包括病毒学家)(676人中的139人)对制定微生物学执业程序的工作组开展的一项调查做出了回应,该调查旨在确定当前的做法,并就微生物学记录标准制定行业内一致认可的建议。所使用的调查记录方法的累积频率表明,不同时间有65%(139人中的90人)的受访者使用日志,62%(139人中的86人)使用临床申请卡背面,57%(139人中的79人)使用计算机记录,22%(139人中的30人)使用索引卡系统记录微生物学建议,这表明医学微生物学家在维护临床记录的方式上存在很大差异。