Dollery C T, Beilin L J, Bulpitt C J, Coles E C, Johnson B F, Munro-Faure A D, Turner S C
Br Heart J. 1977 Feb;39(2):181-5. doi: 10.1136/hrt.39.2.181.
The initial record of history and clinical findings has been studied in 278 patients attending three hypertension clinics. Half of these were randomly allocated to standard case notes and the other half to a special structured questionnaire record. The investigations carried out in a total of 521 patients with raised arterial pressures were examined. The records derived from the structured questionnaire were much more complete than the standard case notes but the difference was less obvious for a positive record than a negative one. None of the investigations was carried out in all patients, even though it was the policy of the clinics that most of them should be. A possible aetiological diagnosis was made in 28 patients and, at the time of writing, 3 patients had benefited from a surgical operation carried out as a result of investigation. These results raise the question of the quality of the initial care of hypertensive patients and suggest that the structured questionnaires might lead to an improvement. It remains to be established whether all the information collected does influence the outcome in patients with hypertension.
对三家高血压诊所的278名患者的病史和临床检查初始记录进行了研究。其中一半患者被随机分配到使用标准病历，另一半则使用特殊的结构化问卷记录。对总共521名动脉压升高患者所进行的检查进行了审视。源自结构化问卷的记录比标准病历要完整得多，但阳性记录与阴性记录相比，差异没那么明显。即使诊所的政策是大多数检查都应对所有患者进行，但并非所有患者都接受了所有检查。28名患者做出了可能的病因诊断，在撰写本文时，有3名患者因检查结果接受了外科手术并从中受益。这些结果引发了高血压患者初始护理质量的问题，并表明结构化问卷可能会带来改善。所收集的所有信息是否真的会影响高血压患者的治疗结果仍有待确定。
