Smallwood K G, Kick S D, Beal J A, Saizow R B, Jarolim D R
Adult Medicine Clinic, OUHSC, Tulsa, OK 74129.
J Okla State Med Assoc. 1991 Oct;84(10):516-25.
A retrospective review of the medical records of 45 patients with human immunodeficiency virus (HIV) disease was conducted in an Oklahoma internal medicine teaching clinic. Demographics of this patient population and house staff performance in the care of these patients was evaluated. The study population demographics were similar to national findings with the exception of lower documented homosexual/bisexual transmission among males and higher heterosexual transmission among females. Deficiencies in documentation were noted in the areas of route of acquisition, mental status, and functional level. In several instances patients who were candidates for zidovudine and/or Pneumocystis prophylaxis were not receiving these treatments. The quality of care could be enhanced through the use of HIV evaluation and treatment protocols as well as specially designed, HIV-specific medical records to improve data collection. These HIV-specific medical records can be found in the appendices.
在俄克拉荷马州的一家内科教学诊所，对45例人类免疫缺陷病毒（HIV）疾病患者的病历进行了回顾性研究。评估了该患者群体的人口统计学特征以及住院医师对这些患者的护理表现。该研究人群的人口统计学特征与全国研究结果相似，只是男性中记录的同性恋/双性恋传播率较低，而女性中的异性传播率较高。在感染途径、精神状态和功能水平等方面的记录存在不足。在一些情况下，符合齐多夫定和/或肺孢子虫预防条件的患者未接受这些治疗。通过使用HIV评估和治疗方案以及专门设计的、针对HIV的病历以改善数据收集，可以提高护理质量。这些针对HIV的病历可在附录中找到。
