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瑞典牙科护理中患者记录的质量评估。

Quality evaluation of patient records in Swedish dental care.

作者信息

Rasmusson L, René N, Dahlbom U, Borrman H

机构信息

Faculty of Odontology, University of Gothenburg, Sweden.

出版信息

Swed Dent J. 1994;18(6):233-41.

PMID:7725237
Abstract

The purposes of this study were to evaluate systematically five patient records each from randomly selected dentists in different regions of Sweden in 1992, and to see whether the good knowledge of some record-keeping rules, noted earlier, was reflected in practical observance of the rules as a whole. Observance was generally poor: in nearly 40% of the variables investigated, the documentation did not follow the rules. Patient history, status, diagnosis, therapy plans and other important information were often missing among the records from the general practitioners. The specialists' records, however, were in general very accurate. As a whole, Swedish dental patient records constitute poor antemortem material for forensic odontology. The dentist's age is related to the quality of the records. The standard of the patient records must be improved.

摘要

本研究的目的是在1992年对瑞典不同地区随机挑选的牙医的五份患者记录进行系统评估,以了解先前发现的对某些记录保存规则的良好认知是否体现在对这些规则的整体实际遵守情况中。总体遵守情况较差:在近40%的调查变量中,文件记录未遵循规则。全科医生的记录中经常缺少患者病史、状况、诊断、治疗计划和其他重要信息。然而,专科医生的记录总体上非常准确。总体而言,瑞典牙科患者记录作为法医牙科学的生前材料质量较差。牙医的年龄与记录质量有关。患者记录的标准必须提高。

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