Dickie G L, Bass M J
J Fam Pract. 1980 Mar;10(3):487-90.
In a teaching family medical center a strategy was sought to improve the quality of medical record keeping. A study was undertaken to determine the usefulness of a standardized form for self-audit. Validity and reliability of the form were established and it was shown that there was a significant improvement in the study group three weeks after the exposure period, as compared to a control group. Improvements occurred particularly in the recording of drugs prescribed and in the linkage of progress notes to the problem list. Despite this improvement, linkage to the problem list was seen to occur in only half of the studied charts. With modification the self-audit form appears to be a useful stimulus to good record keeping.
在一家教学型家庭医疗中心，人们寻求一种策略来提高病历记录的质量。开展了一项研究以确定标准化自我审核表格的实用性。该表格的有效性和可靠性得到了确立，结果表明，与对照组相比，暴露期三周后研究组有显著改善。尤其在处方药物记录以及病程记录与问题清单的关联方面有所改善。尽管有这种改善，但在仅一半的研究病历中发现了与问题清单的关联。经过修改，自我审核表格似乎是促进良好记录保存的有用手段。
