Patel A G, Mould T, Webb P J
Medway District General Hospital, Kent.
Ann R Coll Surg Engl. 1993 Jan;75(1 Suppl):7-9.
We have assessed the extent to which hospital records follow the Guidelines for Medical Records and Notes published by the Royal College of Surgeons of England. Notes of 100 consecutive discharges were reviewed from two surgical units, one at a District General Hospital (DGH) and the other at a London Teaching Hospital (TH). Overall, only 65 per cent (DGH) and 67 per cent (TH) of the entries specified by College guidelines were both present and correct. Substandard categories included the regular update of notes, post-operative instructions, comments about post-operative recovery, the record of advice given to relatives and incorrect consent. The guidelines produced by the Royal College of Surgeons are being applied, but there is room for considerable improvement. Inadequate medical records limit audit and may have medico-legal consequences. We recommend regular assessment of the standard of note keeping.
我们评估了医院病历遵循英国皇家外科医学院发布的《病历与记录指南》的程度。从两个外科科室连续抽取了100份出院记录进行审查，一个科室位于地区综合医院（DGH），另一个位于伦敦教学医院（TH）。总体而言，学院指南规定的条目只有65%（DGH）和67%（TH）同时存在且正确。不合标准的类别包括记录的定期更新、术后医嘱、关于术后恢复的评论、给亲属的建议记录以及同意书错误。皇家外科医学院制定的指南正在实施，但仍有很大的改进空间。不充分的病历会限制审计，并可能产生医疗法律后果。我们建议定期评估病历记录的标准。
