The Department of Social and Preventive Medicine, Université de Montréal, Montréal, Canada.
Int J Qual Health Care. 2012 Dec;24(6):564-7. doi: 10.1093/intqhc/mzs034. Epub 2012 Jul 13.
Medical recordkeeping is essential to assuring quality health care. Records aid in the medical management of patients while serving epidemiological purposes. Medical recordkeeping is often inadequate in resource-limited settings, which threatens the quality of health care. In this study, by way of example, we make the case for increased attention to medical recordkeeping by illustrating how poor charting and archiving can threaten the quality of care. We make suggestions to improve the adequacy of medical recordkeeping by emphasizing recent technological innovations applied to resource-limited settings and the need to instil a culture of recordkeeping.
病历记录对于确保医疗质量至关重要。记录有助于对患者进行医疗管理，同时也有助于进行流行病学研究。在资源有限的环境中，病历记录往往不够完善，这会威胁到医疗质量。在本研究中，我们举例说明了病历记录不完善如何威胁到医疗质量，从而强调了加强对病历记录的重视。我们提出了一些建议，通过强调应用于资源有限环境中的最新技术创新以及树立记录文化的必要性，来提高病历记录的充分性。
