Twigg J, Briggs T, Parker C, Miller R
Whittington Hospital, London, UK.
Postgrad Med J. 1993 Jul;69(813):578-80. doi: 10.1136/pgmj.69.813.578.
The increasing emphasis on management responsibilities and audit led us to investigate the state of surgical notes in our hospital. Twelve criteria were evaluated regarding information that should be contained in the notes and the absence of this important information was documented. Deficiencies were revealed in all criteria selected. Until hospital patients files are well kept and maintained, retrospective audit whether financial or medical will not be valid. A significant injection of resources is required to redress the situation. Hospitals which have not carried out detailed studies into the contents of their notes need to do so as a matter of urgency.
对管理职责和审计的日益重视促使我们对我院手术记录的状况进行调查。我们评估了关于手术记录应包含信息的12项标准，并记录了重要信息缺失的情况。所选的所有标准都存在缺陷。在医院患者档案妥善保存和维护之前，无论是财务审计还是医疗审计都将无效。需要大量投入资源来纠正这种情况。尚未对其手术记录内容进行详细研究的医院急需开展此项工作。
