Grauer K
J Fam Pract. 1983 Jan;16(1):121-6.
A prospective audit of process on 1,200 consecutive patients seen in the emergency department by family practice residents was performed at the Family Practice Residency Program in Gainesville, Florida. The overall quality of care delivered conformed to the standards of "good medical care" as judged by the author in 85.6 percent of cases. Resident errors were detected in the remaining 14.4 percent of cases, and occurred most frequently among physicians in the earlier years of training (P less than .005). Ultimate patient management was changed by the audit in only 1 percent of cases but potentially had an important impact on the care of these patients. Errors of inadequate documentation were common among residents irrespective of their level of training. An ongoing audit of emergency department charts with regular feedback on medical process and recording appears to be useful both as an educational tool and as a method of improving emergency care.
在佛罗里达州盖恩斯维尔的家庭医学住院医师项目中，对家庭医学住院医师在急诊科连续诊治的1200例患者的诊疗过程进行了前瞻性审计。根据作者的判断，在85.6%的病例中，所提供的整体医疗质量符合“优质医疗”标准。在其余14.4%的病例中发现了住院医师的错误，且这些错误在培训初期的医师中最为常见（P小于0.005）。审计仅在1%的病例中改变了最终的患者管理方式，但可能对这些患者的护理产生了重要影响。无论培训水平如何，住院医师中记录不充分的错误都很常见。对急诊科病历进行持续审计，并定期反馈医疗过程和记录情况，似乎作为一种教育工具和改善急诊护理的方法都很有用。
