Sokas R K, Orellana L, Day S C
University of Pennsylvania School of Medicine, Philadelphia.
J Med Educ. 1988 Feb;63(2):125-30. doi: 10.1097/00001888-198802000-00008.
The authors evaluated the effectiveness of chart audit with written feedback as a tool for encouraging second- and third-year residents to obtain and record occupational information during history-taking. Baseline information was obtained by reviewing the charts of 20 residents of patients who presented for complete history-taking and physical examination and scoring for various aspects of occupational history-taking. Intervention was directed at 10 of the residents; the other 10 served as controls. Between five and 12 charts were reviewed for each of the 10 residents in the intervention group; the scoring sheet, scoring criteria, results, and a brief discussion of potentially relevant occupational concerns for the given patient were returned to the resident, along with copies of the relevant pages of the patient's record. Chart review showed no difference in total scores for occupational history-taking between the two groups before intervention. The postintervention scores improved insignificantly for the intervention group; however, the scores deteriorated significantly for the control group (1.38 to 0.92, .05 greater than p greater than .025).
作者评估了采用书面反馈的图表审核作为一种工具的有效性，该工具用于鼓励二年级和三年级住院医师在病史采集过程中获取并记录职业信息。通过查阅20名前来进行全面病史采集和体格检查的患者的住院医师所负责的图表，并对职业病史采集的各个方面进行评分，从而获得基线信息。对10名住院医师进行干预；另外10名作为对照。对干预组的10名住院医师每人查阅5至12份图表；将评分表、评分标准、结果以及对给定患者潜在相关职业问题的简要讨论连同患者记录的相关页面复印件返还给住院医师。图表审核显示，干预前两组在职业病史采集的总分上没有差异。干预组干预后的分数改善不明显；然而，对照组的分数显著恶化（从1.38降至0.92，.05大于p大于.025）。
