Jachuck S J, Price P, Bound C L
Br Med J (Clin Res Ed). 1984 Jul 7;289(6436):26-8. doi: 10.1136/bmj.289.6436.26.
The quality of contents of general practice records was assessed by retrieving clinical information pertaining to hypertension in 171 consecutive records, and the quality of communication storage was assessed by seeking evidence of tuberculin skin tests or BCG vaccination, or both, in 298 consecutive records. There was no mention of urine analysis and blood test results in 43.3% and no record of fundal examination in 61.4% of the records of patients with hypertension. Electrocardiography was performed in 67.8% and chest x ray examination was done in 65.5% of these patients. These observations have importance for patient care, education, and research. The information regarding tuberculin skin test or BCG immunization, or both, was not available in 78% of the records. Reassessment of the individuals, however, showed that 89% of the studied population had had the test or vaccination, or both. There was thus a deficiency in communication and storage.
通过检索171份连续病历中与高血压相关的临床信息,评估了全科医疗记录的内容质量;通过在298份连续病历中查找结核菌素皮肤试验或卡介苗接种或两者的证据,评估了沟通记录的质量。43.3%的高血压患者病历中未提及尿液分析和血液检查结果,61.4%的病历中没有眼底检查记录。这些患者中67.8%进行了心电图检查,65.5%进行了胸部X光检查。这些观察结果对患者护理、教育和研究具有重要意义。78%的病历中没有关于结核菌素皮肤试验或卡介苗免疫或两者的信息。然而,对个体的重新评估显示,89%的研究人群进行了该项检查或接种,或两者都有。因此,在沟通和记录方面存在不足。