Chamisa I, Zulu B M W
Department of Surgery, Prince Mishyeni Memorial Hospital, Mobeni, Durban.
S Afr J Surg. 2007 Aug;45(3):92, 94-5.
A high standard of medical record keeping is important for safe patient care and provides information for research, audit and medicolegal purposes. Standards exist on what entries should contain, but as far as we are aware these standards are not regularly used in South Africa. We compared surgical case notes at Prince Mishyeni Hospital with guidelines from the Royal College of Surgeons of England.
A prospective series of 204 case notes was randomly selected and reviewed.
There was an 80% compliance rate for 16/35 standards, and 100% was achieved for 8 operation sheet standards. The following fell short of 80% compliance: patient's name on every page (71%), hospital number on every page (50%), every entry timed (16%), clinician's name printed on every note (8%), clinician's designation on every entry (2%), an entry each weekday (77%), type of admission (9%), presenting complaint (61%), history of presenting complaint (65%), previous medical history (76%), drug history (47%), allergies (59%), social history (34%), family history (11%), each entry legible (65%), and anaesthetist's name (69%). Test results were signed and radiograph test results initialled in 25% and 17% of cases respectively.
Legal requirements, good practice, research and teaching all demand notes that are detailed and of high quality. This study shows that medical records are grossly inadequate in many respects. Better education of junior staff and regular auditing of medical records could improve this.
高标准的病历记录对于患者的安全护理至关重要，并且可为研究、审计及法医学目的提供信息。关于病历记录应包含哪些内容已有相关标准，但据我们所知，这些标准在南非并未得到定期使用。我们将米申耶尼王子医院的外科病例记录与英国皇家外科医学院的指南进行了比较。
前瞻性地随机选取了204份病例记录并进行审查。
16/35项标准的符合率为80%，8项手术记录标准的符合率达到了100%。以下项目的符合率未达到80%：每页都有患者姓名（71%）、每页都有医院编号（50%）、每条记录都标注时间（16%）、每份记录都打印有临床医生姓名（8%）、每条记录都有临床医生职称（2%）、每个工作日都有记录（77%）、入院类型（9%）、主诉（61%）、主诉病史（65%）、既往病史（76%）、用药史（47%）、过敏史（59%）、社会史（34%）、家族史（11%）、每条记录清晰可读（65%）以及麻醉医生姓名（69%）。分别有25%和17%的病例的检查结果有签字，X光检查结果有标注姓名首字母。
法律要求、良好的医疗实践、研究及教学都需要详细且高质量的记录。本研究表明，病历记录在很多方面都严重不足。加强对初级员工的教育以及定期对病历记录进行审计可能会改善这种情况。
