Duggan A K, Starfield B, DeAngelis C
Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, Maryland.
Pediatrics. 1990 Jan;85(1):104-13.
The impact of record format on provider performance and recording of the process of care and their concordance were examined in this study. The process of care was defined by existing sets of explicit criteria developed for quality assessment. The study was conducted in an urban teaching hospital pediatric primary care clinic. Housestaff were encouraged, but not required, to use the clinic's structured, age-specific forms for recording well-child care. Performance and recording were compared during required well-child visits using the structured form and those using the basic clinic form. Study data from 1031 visits to 68 housestaff during a 14-month period were collected using medical record abstracting of all visits and direct observation of 243 of them. Twenty-three of the providers were assigned randomly to an unobserved control group to assess the effect of observation on recording. Use of the structured form was associated with significantly higher levels of both recorded and observed performance. When performance could be merely checked off to document performance, overdocumentation was found. Record-based estimates of performance were more accurate during visits when the structured form was used. Record format can improve provider performance and recording of the process of care.
本研究考察了记录格式对医疗服务提供者的表现、医疗过程记录以及两者一致性的影响。医疗过程由为质量评估制定的现有明确标准集来定义。该研究在一家城市教学医院的儿科初级保健诊所进行。鼓励住院医师（但不要求）使用该诊所结构化的、针对特定年龄的表格来记录儿童健康护理情况。在儿童定期健康检查中，对使用结构化表格和使用诊所基本表格的情况进行了表现和记录方面的比较。在14个月期间，通过对所有就诊记录进行病历摘要以及对其中243次就诊进行直接观察，收集了68名住院医师的1031次就诊的研究数据。随机将23名医疗服务提供者分配到一个未被观察的对照组，以评估观察对记录的影响。使用结构化表格与记录和观察到的表现水平显著更高相关。当只需勾选来记录表现时，发现存在记录过度的情况。在使用结构化表格的就诊期间，基于记录的表现估计更准确。记录格式可以提高医疗服务提供者的表现以及医疗过程的记录。
