Tully Mary P, Cantrill Judith A
School of Pharmacy and Pharmaceutical Sciences, University of Manchester, UK.
J Eval Clin Pract. 2005 Oct;11(5):430-7. doi: 10.1111/j.1365-2753.2005.00553.x.
RATIONALE, AIMS AND OBJECTIVES: Extraction of prescribing data from medical records is a common, albeit flawed, research method. Yet little is known about the processes that result in those data. This study explores the creation and use of prescribing documentation in the medical record, from the perspective of the hospital doctors who both create and use it.
Thirty-six hospital doctors were purposely selected for qualitative interviews, giving a maximum variability sample of grades of doctors across the range of major medical specialty areas and medical teams at a large teaching hospital in England.
The findings suggest a number of reasons why hospital doctors fail to record prescribing decisions in the medical record. There was no set standard, record keeping was not formally taught and the hurried environment of the ward gave little time for documentation. The doctors also acknowledged that there was no need for completeness, as colleagues would be able to 'fill in the gaps' via an inferential process. Assumptions were made and although this was not seen as ideal, it was recognized as necessary if work was to be done efficiently.
These results reinforce the suggestion that, despite the large number of potential users, the medical record is created for those with the right privileged knowledge. This has profound implications for those without that insider knowledge who are using medical records for research purposes.
This work was funded by a North West Regional National Health Service Postdoctoral Fellowship.
原理、目的与目标：从医疗记录中提取处方数据是一种常见的研究方法，尽管存在缺陷。然而，对于产生这些数据的过程却知之甚少。本研究从创建和使用医疗记录的医院医生的角度，探讨了医疗记录中处方文档的创建和使用情况。
特意挑选了36名医院医生进行定性访谈，以获取英国一家大型教学医院各主要医学专业领域和医疗团队中不同级别医生的最大变异性样本。
研究结果表明了医院医生未在医疗记录中记录处方决策的若干原因。没有固定标准，记录保存未得到正式教授，病房忙碌的环境也几乎没有时间进行文档记录。医生们还承认，无需做到完整，因为同事能够通过推理过程“填补空白”。存在一些假设，虽然这并非理想情况，但如果要高效开展工作，这被认为是必要的。
这些结果强化了这样一种观点，即尽管潜在用户众多，但医疗记录是为拥有特定特权知识的人创建的。这对于那些没有内部知识却将医疗记录用于研究目的的人具有深远影响。
这项工作由西北区域国民健康服务博士后奖学金资助。
