Dunn R B, Day R W, Hall M R
Age Ageing. 1987 Jul;16(4):225-8. doi: 10.1093/ageing/16.4.225.
A form developed to audit the case notes of general medical patients was modified for use in geriatric medicine. The case notes of 41 admissions to the geriatric wards of a teaching hospital were audited with the new form and their contents did not come up to the standard set. Deficiencies were found in those parts of the notes considered to reflect the distinctive features of the specialty, e.g. the functional history, the assessment of mobility and the recording of multidisciplinary case conferences. The introduction of a standard history and examination form to meet the needs of patients admitted to geriatric wards, better training in geriatric medicine for junior doctors and closer scrutiny of medical records by consultants are suggested as ways of improving documentation in the case notes.
一份用于审核普通内科患者病历的表格被修改后用于老年医学。采用新表格对一家教学医院老年病房的41份住院病历进行了审核，发现其内容未达到设定的标准。在病历中被认为能反映该专科特色的部分存在不足，如功能史、活动能力评估以及多学科病例讨论会记录等。建议引入一份符合老年病房住院患者需求的标准病史和检查表格，对低年资医生进行更好的老年医学培训，并由会诊医生对病历进行更严格的审查，以此作为改进病历记录的方法。
