Wrenn K, Rodewald L, Lumb E, Slovis C
Department of Emergency Medicine, Vanderbilt University, Nashville, TN.
Ann Emerg Med. 1993 May;22(5):805-12. doi: 10.1016/s0196-0644(05)80796-6.
To assess the effect of preprinted, structured, complaint-specific patient encounter forms on documentation, use of testing, and treatment compared with free-text record keeping.
Nonrandomized case-control trial.
University-affiliated, tertiary referral hospital emergency department.
The records of all patients with lacerations, pharyngitis, asthma, or isolated closed-head injury during an eight-month period were reviewed.
Use of structured complaint-specific patient encounter forms versus traditional free-text record keeping.
The null hypothesis was that there would be no differences in documentation, test use, or practice when the structured forms were used compared with free-text record keeping.
Differences in documentation that favored the use of the structured forms for all four problems studied were seen consistently. Not only was documentation improved, but test use also was affected in a way that decreased use. In addition, in certain areas (eg, treatment of pharyngitis), clinical practice also was changed.
Structured, problem-specific ED records improve documentation and affect both resource use and clinical practice. These forms may be useful for improving communication and reimbursement as well as for medicolegal documentation. They provide a method for standardized quality assurance review and clinical data abstraction. Finally, they provide a method for active dissemination of clinical standards.
评估预先印制的、结构化的、针对特定投诉的患者接诊表格与自由文本记录相比，对文档记录、检查使用和治疗的影响。
非随机病例对照试验。
大学附属医院的三级转诊医院急诊科。
回顾了八个月期间所有有撕裂伤、咽炎、哮喘或孤立性闭合性颅脑损伤患者的记录。
使用结构化的针对特定投诉的患者接诊表格与传统的自由文本记录。
原假设是与自由文本记录相比，使用结构化表格时在文档记录、检查使用或诊疗方面不会有差异。
在所有研究的四个问题上，始终发现有利于使用结构化表格的文档记录差异。不仅文档记录得到改善，检查使用也受到影响，使用量减少。此外，在某些领域（如咽炎治疗），临床实践也发生了变化。
结构化的、针对特定问题的急诊记录可改善文档记录，并影响资源使用和临床实践。这些表格可能有助于改善沟通和报销，以及用于法医学文档记录。它们提供了一种标准化质量保证审查和临床数据提取的方法。最后，它们提供了一种积极传播临床标准的方法。
