Horrocks Emma, Roake Justin, Lewis David
Department of Vascular, Endovascular and Transplant Surgery, Christchurch Hospital, Private Bag 4710, Christchurch, New Zealand.
N Z Med J. 2008 May 23;121(1274):42-9.
Varicose veins are a significant health problem which attract much medicolegal attention. Recent publications have suggested "best practice" regarding assessment of patients with varicose veins. A retrospective audit was performed comparing clinical practice in a New Zealand teaching hospital with suggested standards.
Clinic letters from 80 patients awaiting varicose vein surgery were reviewed. Data were collated regarding presenting problem, relevant medical history, clinical findings on examination, further investigations, and outcome.
Presenting complaint was noted for 99% of patients but actual symptoms were only recorded for 41%. The degree of disability caused by varicose veins was documented for 33% and patient concerns in 4%. Half of the patients presented with leg ulcers but ankle-brachial indices (ABPIs) were only recorded in 26% of clinic letters. Duplex scanning was recommended prior to surgery for 69% of patients and hand held Doppler assessment of venous disease was recorded in 61% cases. Clinic letters did not specify the nature and extent of disease in 6% of cases, and although every patient was recommended for surgery, the exact procedure was specified in only 24%. Details of surgical risks and complications were only present in 20% of letters, and only 21% of patients received a printed information sheet.
The quality of the data recorded in the clinic letters of fell below suggested standards for assessment of patients with varicose veins. Improving the documentation of patient assessment will allow better communication between providers of healthcare and make clinical errors less likely.
静脉曲张是一个重大的健康问题，备受法医学关注。近期的出版物提出了关于静脉曲张患者评估的“最佳实践”。进行了一项回顾性审计，将一家新西兰教学医院的临床实践与建议标准进行比较。
回顾了80例等待静脉曲张手术患者的临床信件。整理了关于就诊问题、相关病史、检查时的临床发现、进一步检查及结果的数据。
99%的患者记录了就诊主诉，但实际症状仅记录了41%。记录了静脉曲张导致的残疾程度的患者占33%，记录了患者担忧的占4%。一半的患者有腿部溃疡，但仅26%的临床信件记录了踝臂指数（ABPI）。69%的患者在手术前建议进行双功扫描，61%的病例记录了手持多普勒评估静脉疾病情况。6%的病例临床信件未明确疾病的性质和范围，尽管每个患者都被建议进行手术，但仅24%明确了具体手术方式。手术风险和并发症的细节仅在20%的信件中出现，仅21%的患者收到了印刷的信息单。
静脉曲张患者临床信件中记录的数据质量低于建议的评估标准。改善患者评估的记录将有助于医疗服务提供者之间更好地沟通，并减少临床失误的可能性。
