对英国基于全科医生的计算机化数据资源所记录信息的验证。
Validation of information recorded on general practitioner based computerised data resource in the United Kingdom.
作者信息
Jick H, Jick S S, Derby L E
机构信息
Boston Collaborative Drug Surveillance Program, Boston University Medical Center, Lexington, MA 02173-5207.
出版信息
BMJ. 1991 Mar 30;302(6779):766-8. doi: 10.1136/bmj.302.6779.766.
OBJECTIVE
To determine the extent of agreement between clinical information recorded on surgery computers of selected general practitioners and similar information in manual records of letters received from hospital consultants and kept in the general practitioners' files.
DESIGN
Hospital consultants' letters in the manual records of selected general practitioners were photocopied and the consultants' clinical diagnoses were compared with diagnoses recorded on computer.
SETTING
General practices in the United Kingdom using computers provided by VAMP Health for recording clinical information.
SUBJECTS
2491 patients who received one of three non-steroidal anti-inflammatory drugs and who attended 58 practices whose computer recorded data were considered after a preliminary review to be of satisfactory quality.
RESULTS
Among 1191 patients for whom consultants' letters were forwarded a clinical diagnosis reflecting the diagnosis noted on a consultant letter was present on the computer record for 1038 (87%).
CONCLUSION
Clinical information available on the computer records of the general practitioners who participated in this study is satisfactory for many clinical studies.
目的
确定部分全科医生手术电脑上记录的临床信息与医院会诊医生信件手工记录中并保存在全科医生档案里的类似信息之间的一致程度。
设计
对部分全科医生手工记录中的医院会诊医生信件进行复印，并将会诊医生的临床诊断与电脑记录的诊断进行比较。
背景
英国使用VAMP Health提供的电脑记录临床信息的全科诊所。
研究对象
2491名接受了三种非甾体抗炎药之一治疗且就诊于58家诊所的患者，这些诊所的电脑记录数据经初步审查质量令人满意。
结果
在转寄了会诊医生信件的1191名患者中，电脑记录上有1038名（87%）存在反映会诊医生信件中所记录诊断的临床诊断。
结论
参与本研究的全科医生电脑记录中的临床信息对许多临床研究而言是令人满意的。
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