Shekelle P G, Kosecoff J
UCLA Division of General Internal Medicine, Department of Medicine.
Am J Public Health. 1992 Jan;82(1):115-7. doi: 10.2105/ajph.82.1.115.
Sexually transmitted diseases occur disproportionately among the poor, are often treated in public hospitals and clinics, and have not been subjected to quality-of-care evaluation. We designed a medical record abstraction system using well-established, specific process-of-care criteria drawn from the medical literature and experts and grouped into three levels of quality: excellent, adequate, and minimal. One hundred seventy-six consecutive patients were identified from the clinic logbook and their medical records abstracted. Deficiencies in history taking, physical examination, laboratory testing, treatment, and public health reporting were identified.
性传播疾病在贫困人口中发病率过高，通常在公立医院和诊所接受治疗，且尚未接受医疗质量评估。我们设计了一个病历摘要系统，该系统采用了从医学文献和专家那里获取的既定、具体的医疗过程标准，并分为三个质量等级：优秀、 adequate和最低。从诊所日志中识别出176名连续就诊的患者，并对他们的病历进行摘要。发现了病史采集、体格检查、实验室检测、治疗和公共卫生报告方面的不足。
