Westgren M, Divon M, Greenspoon J, Paul R
Am J Obstet Gynecol. 1986 Aug;155(2):269-71. doi: 10.1016/0002-9378(86)90806-9.
In retrospective chart reviews there are often a certain number of missing hospital records. To elucidate this variable we compared the outcomes of very low birth weight breech infants with respect to the method of collecting data. A prospective sampling, during the hospital stay, of data was performed in 1979 to 1980 and in 1983 to 1984, and the frequencies of very low birth weight were 1.89 and 1.90, respectively, per 1000 live births. For 1981 to 1982 a retrospective record search was performed with the use of the ordinary medical record search system at this institution. For this period 39 of 52 (75%) hospital records were recovered, giving an apparent frequency of 1.32/1000 live births, which differed significantly from either period studied prospectively. An analysis of demographic data of the three groups revealed that the mean gestational age and the mean birth weights were higher in the period studied retrospectively compared with both periods studied prospectively and that the neonatal mortality rates were higher in the periods studied prospectively (74.1% and 57.1%, respectively) than in the period studied retrospectively (28.2%). It is concluded that the more complicated a clinical case is, the more likely the record will not be found for retrospective chart review. This problem should be kept in mind, and it ought to be a requirement that the number of missing charts be stated in retrospective observational studies.
在回顾性病历审查中，常常会有一定数量的医院记录缺失。为了阐明这一变量，我们比较了极低出生体重臀位婴儿在数据收集方法方面的结局。1979年至1980年以及1983年至1984年期间，在住院期间进行了前瞻性数据抽样，极低出生体重的发生率分别为每1000例活产1.89例和1.90例。1981年至1982年期间，使用该机构的普通病历检索系统进行了回顾性记录检索。在此期间，52份医院记录中有39份（75%）被找回，活产婴儿中极低出生体重的明显发生率为1.32/1000，这与前瞻性研究的任何一个时期都有显著差异。对三组人口统计学数据的分析显示，回顾性研究期间的平均胎龄和平均出生体重均高于前瞻性研究的两个时期，且前瞻性研究时期的新生儿死亡率（分别为74.1%和57.1%）高于回顾性研究时期（28.2%）。结论是，临床病例越复杂，回顾性病历审查时越有可能找不到记录。应牢记这一问题，并且在回顾性观察研究中应要求说明缺失病历的数量。
