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27家培训诊所的病历摘要格式与内容

Format and content of medical record summaries in 27 training practices.

作者信息

Presley P

出版信息

J R Coll Gen Pract. 1988 Jan;38(306):26-7.

PMID:3204548
原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC1711374/
Abstract

Twenty seven established trainers enrolled on an advanced course for trainers were sent a set of medical records with the instruction to summarize them as they would any set of records going into their practice. The main finding of the study was the great variability of the summaries produced, often owing to the failure to include important information from the continuation cards. The need for nationally recognized standards in summary making is discussed.

摘要

27名已获认证的培训师参加了一门培训师进阶课程,他们收到了一组病历,并被要求像对待进入他们诊所的任何一组病历来总结这些病历。该研究的主要发现是所生成总结的巨大差异,这通常是由于未能纳入延续卡中的重要信息。文中讨论了制定全国公认的总结标准的必要性。