Schmidt Martina, Rizvi Nilofar, Lee David M, Wood Vanessa, Amisano Suzanne, Fairley Christopher K
Melbourne Sexual Health Centre, 580 Swanston Street, Carlton, Victoria 3053, Australia.
Int J STD AIDS. 2005 Dec;16(12):822-4. doi: 10.1258/095646205774988073.
The completeness of a random sample of medical records, before and after introduction of a pro forma, was measured in an audit. Twenty key variables that were considered as an essential part of every clinical history were assessed. There was a significant improvement in nine of the 18 items for men, and 11 of the 20 items for women. The mean completeness score increased from 14.5 to 15.9 (out of 18) in men, and from 15 to 17.5 (out of 20) in women (P < 0.001). The improved completeness of medical records as a result of the pro forma should result in the improved management of clients, in addition to providing improved documentation in the case of a medicolegal case.
在一次审计中，对采用统一表格前后的随机抽取的病历样本完整性进行了测量。评估了被视为每份临床病史重要组成部分的20个关键变量。男性的18项中有9项有显著改善，女性的20项中有11项有显著改善。男性的平均完整性得分从14.5分（满分18分）提高到15.9分，女性从15分（满分20分）提高到17.5分（P < 0.001）。统一表格使病历完整性得到改善，这除了能在医疗法律案件中提供更好的文件记录外，还应能改善对客户的管理。
