Starfield B, Steinwachs D, Morris I, Bause G, Siebert S, Westin C
Med Care. 1979 Jul;17(7):758-66. doi: 10.1097/00005650-197907000-00006.
This study was designed to determine the extent to which the medical record contained evidence of coordination of care. Coordination of care was defined as the recognition of information (problems, therapies, intervening visits and tests) about patients from one visit to a follow-up visit. Overall, there was concordance between the medical record and independent observation of the physician-patient interaction in 70-85 per cent of instances. When there was clear indication that the practitioner recognized the information, the chart contained evidence of this recognition 68-85 per cent of the time, depending on the type of information. However, if the information was highly salient, the record contained evidence of recognition in a much greater percentage of intances: 95 per cent for distinctly identified problems, 83 per cent for problems which were contained within the text of progress notes, 96 per cent for major drugs, and 94 per cent for abnormal tests. The data from this study support the less direct evidence of others that the medical record adequately reflects extent of recognition of important information about patients by practitioners.
本研究旨在确定病历中包含护理协调证据的程度。护理协调被定义为在一次就诊到后续就诊过程中对患者信息（问题、治疗、中间就诊和检查）的识别。总体而言，在70%至85%的情况下，病历与对医患互动的独立观察结果一致。当有明确迹象表明从业者识别了信息时，根据信息类型，图表在68%至85%的时间里包含了这种识别的证据。然而，如果信息非常突出，记录中包含识别证据的情况比例要高得多：明确识别的问题为95%，病程记录文本中包含的问题为83%，主要药物为96%，异常检查为94%。这项研究的数据支持了其他人的间接证据，即病历充分反映了从业者对患者重要信息的识别程度。
