分娩中心产前记录缺失：沟通问题量化分析
Missing prenatal records at a birth center: a communication problem quantified.
作者信息
Miller Donald W, Yeast John D, Evans Robin L
机构信息
eNATAL, LLC, Shawnee, KS, USA.
出版信息
AMIA Annu Symp Proc. 2005;2005:535-9.
OBJECTIVES
To quantify the extent of missing prenatal records at the time of patient presentation to a birth center, to document the age of the information in those records, and to discover how quickly missing records were retrieved.
METHOD
A survey form was completed over a three-month period for each patient presenting for care.
RESULTS
Prenatal records were unavailable 37% of the time at initial presentation. Records were never obtained for 20% of patients. The median age of the prenatal record was 30 days for those records that were immediately available, and the median age was 5 days for those records that were retrieved later. It took a median of 1.4 hours to retrieve a missing re-cord.
CONCLUSION
Prenatal records are frequently missing at the point-of-care, and even when records are avail-able or retrieved, the information contained within them is likely to be outdated. Further research is needed to quantify both the clinical and economic impact of this problem.
目的
量化患者就诊于分娩中心时产前记录缺失的程度，记录这些记录中信息的时效性，并了解缺失记录的找回速度有多快。
方法
在三个月的时间里，为每位前来就诊的患者填写一份调查问卷。
结果
初次就诊时，37%的情况下产前记录无法获取。20%的患者从未拿到过记录。即时可得的产前记录的中位时长为30天，之后找回的记录的中位时长为5天。找回一份缺失记录的中位时间为1.4小时。
结论
在医疗服务点，产前记录经常缺失，即使记录可得或已找回，其中包含的信息也可能过时。需要进一步研究来量化这一问题的临床和经济影响。
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