Romm F J, Putnam S M
Med Care. 1981 Mar;19(3):310-5. doi: 10.1097/00005650-198103000-00006.
The medical record is the source of information for many purposes, including evaluation of the quality of care provided. Despite this reliance on the record, there have been few attempts to validate the recorded content against the verbal content of the interaction between patient and physician. In this study, we compared the record with verbatim transcripts of outpatient visits. Overall, 59 per cent of units of information present in either source were found in the record. Recording was more complete for the chief complaint (92 per cent) and information related to the patient's present illness (71 per cent) than for other medical history (29 per cent). Incomplete recording of elicited information may partially explain the often low levels of performance of recommended care items found in quality-of-care studies. We suggest that more attention be paid to improving communication about tests and therapies to patients.
病历是多种用途的信息来源，包括评估所提供的医疗质量。尽管对病历存在这种依赖，但很少有人尝试将记录的内容与患者和医生之间互动的口头内容进行验证。在本研究中，我们将病历与门诊就诊的逐字记录进行了比较。总体而言，在任一来源中存在的59%的信息单元在病历中被发现。主诉（92%）和与患者当前疾病相关的信息（71%）的记录比其他病史（29%）更完整。所引出信息的记录不完整可能部分解释了在医疗质量研究中经常发现的推荐护理项目执行水平较低的情况。我们建议更多地关注改善与患者关于检查和治疗的沟通。
