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门诊病历中的家族健康史记录。

Documentation of family health history in the outpatient medical record.

作者信息

Crouch M A, Thiedke C C

出版信息

J Fam Pract. 1986 Feb;22(2):169-74.

PMID:3484779
Abstract

In a university-based family practice residency program, patients' computerized medical records were audited to determine how information about family health history was recorded. Family history items were listed on the problem lists for only 4.4 percent of all active patients and for only 2.7 percent of a systematic sample of 375 patients. A manual audit of 75 charts randomly selected from the systematic sample showed that the problem lists contained only 5.8 percent of the family history items reported by patients. Children's problem lists contained fewer family history items than did those of adults.

摘要

在一个以大学为基础的家庭医疗住院医师培训项目中,对患者的计算机化病历进行了审核,以确定家族健康史信息是如何记录的。在所有现症患者中,只有4.4%的患者的问题清单上列出了家族史项目;在375名患者的系统抽样中,这一比例仅为2.7%。对从系统抽样中随机抽取的75份病历进行人工审核发现,问题清单中仅包含患者报告的家族史项目的5.8%。儿童的问题清单中包含的家族史项目比成人的少。

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