Davenport R J, Dennis M S, Warlow C P
Department of Clinical Neurosciences, Western General Hospital, Edinburgh.
Age Ageing. 1995 Jan;24(1):43-8. doi: 10.1093/ageing/24.1.43.
In this study we examine whether the introduction of a clerking pro forma improves the completeness of the recording of the management of stroke patients and we review methodological issues important in this type of audit. We prospectively identified 244 consecutive stroke patients before and after the introduction of the pro forma. Patient case notes were traced and audited using a specifically designed form. Following the introduction of the pro forma, there was a significant improvement in the completeness of the recording of patient management; no change was observed for those items not included in the pro forma, suggesting a causal effect. We conclude that a stroke clerking pro forma improves the completeness of the recording of the assessment of hospitalized stroke patients; this has implications for clinical practice and future audit and may be applicable to other common conditions. We emphasize that methodological problems associated with a case note audit must be addressed if it is to produce useful, comparative data.
在本研究中，我们考察了引入一份病历记录模板是否能提高中风患者管理记录的完整性，并回顾了这类审计中重要的方法学问题。我们前瞻性地确定了在引入该模板前后的244例连续中风患者。使用专门设计的表格对患者病历进行追踪和审计。引入该模板后，患者管理记录的完整性有了显著提高；对于未包含在模板中的项目未观察到变化，这表明存在因果效应。我们得出结论，中风病历记录模板提高了住院中风患者评估记录的完整性；这对临床实践和未来审计具有启示意义，并且可能适用于其他常见病症。我们强调，如果要产生有用的比较数据，必须解决与病历审计相关的方法学问题。
