Zschokke U, Conen D, Dubach U C
Schweiz Med Wochenschr. 1981 Jan 3;111(1):14-20.
The therapeutic process at a medical outpatient clinic is evaluated. 1800 drug prescriptions for 839 patients issued by 9 medical residents from February to March 1980 were collected prospectively and analyzed by retrospective chart review. Although a rather high frequency of drug prescription (0.83 per consultation) was found, the average of 2 drugs per patient treated was considered to be low. Gastrointestinal drugs were prescribed most frequently (17% of all prescriptions), whereas antimicrobial agents (7%), psychotropic drugs (10%) and cerebrovascular vasodilators (0.8%) were used rarely in comparison with the results of other investigations. Evaluation of choice of drugs and frequency of their use was based on criteria from the literature. Analysis of prescribing patterns of the individual residents provided information about their pharmacotherapeutic peculiarities. Drug use of the group was judged to be satisfactory. The accuracy of the diagnostic workup preceding drug therapy was examined, and for 17% of all prescriptions no diagnosis could be found in the medical record. Furthermore, the chart review revealed unsatisfactory documentation of the drug therapy prescribed, i.e. 20% of prescriptions were not recorded. Educational feedback to the group was given to the residents. It was accepted as valuable information about medical behaviour and performance of the individual.
对一家门诊诊所的治疗过程进行了评估。前瞻性收集了1980年2月至3月9名住院医师为839名患者开具的1800张药物处方,并通过回顾性病历审查进行分析。尽管发现药物处方频率相当高(每次会诊0.83张),但每位接受治疗患者平均使用2种药物被认为较低。胃肠道药物处方最为频繁(占所有处方的17%),而与其他调查结果相比,抗菌药物(7%)、精神药物(10%)和脑血管扩张剂(0.8%)使用较少。根据文献标准对药物选择及其使用频率进行评估。对各住院医师处方模式的分析提供了有关其药物治疗特点的信息。该组的药物使用情况被判定为令人满意。检查了药物治疗前诊断检查的准确性,在所有处方中,有17%在病历中未发现诊断信息。此外,病历审查显示所开药物治疗的记录不令人满意,即20%的处方未记录。已向住院医师提供了针对该组的教育反馈。它被视为有关个人医疗行为和表现的有价值信息。