Rush J P, Chambers L W, Keddy W
QRB Qual Rev Bull. 1986 Dec;12(12):426-30. doi: 10.1016/s0097-5990(16)30090-2.
A one-day study was conducted to confirm evidence of disagreement about which physician was responsible for the care of patients in a teaching hospital. Sixteen percent of the patients reported the responsible physician as someone different from the physician listed on their medical record, and 13% could not provide any physician's name. Significant disagreement was also discovered between the name given by the charge nurse, the patient's identification band, and the face sheet on the patient's chart. Twenty-nine percent of the charts reviewed revealed no documented involvement by the responsible physician within the previous ten days. As a result of the study, the hospital changed its documentation procedures and the hospital and the medical school became aware of the need to improve monitoring of supervision of student physicians.
开展了一项为期一天的研究,以证实教学医院中患者护理责任医生存在意见分歧的证据。16%的患者报告的责任医生与病历上列出的医生不同,13%的患者无法提供任何医生的姓名。同时还发现,负责护士提供的姓名、患者识别腕带和患者病历首页之间存在重大分歧。在审查的病历中,29%显示责任医生在过去十天内没有记录在案的参与情况。研究结果是,医院改变了其记录程序,医院和医学院也意识到有必要加强对实习医生监督的监测。