Ellis P M, Mellsop G W, Peace K A, Wilson J M
Department of Psychological Medicine, Wellington School of Medicine, University of Otago, New Zealand.
Med Educ. 1987 Nov;21(6):493-7. doi: 10.1111/j.1365-2923.1987.tb01409.x.
Clinical auditing and the setting of goals for continuing education are often based on case note reviews. Deficiencies in the comprehensiveness of the recorded case history place some restrictions on the usefulness of such reviews as guides to continuing education programmes. In this study, attempts were made to improve the quality of the data in psychiatric case notes by peer discussion, and by altering the case note recording guidelines. After each educational intervention a further detailed audit of the subsequent case histories was performed. Significant differences emerged in a few subsections of the case notes, but overall there was little change. Possible explanations for these findings are discussed.
临床审计和继续教育目标的设定通常基于病例记录回顾。所记录病史的全面性不足对这类回顾作为继续教育项目指南的实用性造成了一定限制。在本研究中，尝试通过同行讨论以及改变病例记录指南来提高精神科病例记录中的数据质量。每次教育干预后，对后续病史进行了进一步详细审计。病例记录的几个子部分出现了显著差异，但总体变化不大。讨论了这些发现的可能解释。
