Pollock A V
Scarborough Hospital, England.
Acta Chir Belg. 1996 Apr;96(2):51-5.
The verb "to audit" dates from the sixteenth century when it meant "to make an official systematic examination of accounts". If we substitute "diseases and medical interventions" for "accounts", that is what clinical audit means. It is more than merely quality assurance, although that comes into it. It embraces also a great deal of clinical research. It certainly entails the complete, accurate, and honest recording of a doctor's practice. How to start it? That depends on whether you are going to audit the work of your own unit only, or whether you are going to include the work of the whole hospital, region, or country. Whatever you do you must compare the results that you find with those that have been published. Many departments find it impossible to record the outcome of every intervention in a way that allows sensible conclusions to be drawn. To these departments the reporting of critical incidents is a most welcome substitute. Whatever way you go, remember that audit must be interesting and it must produce results that help you to improve your practice.
动词“审计”可追溯到16世纪，当时它的意思是“对账目进行官方的系统检查”。如果我们用“疾病和医疗干预措施”替换“账目”，那就是临床审计的含义。它不仅仅是质量保证，尽管质量保证也包含在其中。它还涵盖了大量的临床研究。它当然需要完整、准确和诚实地记录医生的诊疗行为。如何开展临床审计呢？这取决于你是只审计自己科室的工作，还是要包括整个医院、地区或国家的工作。无论你怎么做，都必须将你发现的结果与已发表的结果进行比较。许多科室发现，不可能以一种能得出合理结论的方式记录每一项干预措施的结果。对于这些科室来说，报告重大事件是一种非常受欢迎的替代方法。无论你采取哪种方式，记住临床审计必须有趣，而且必须产生有助于你改进诊疗行为的结果。
