Del Degan S, Clavet D, Baillargeon L
Département de médecine familiale, Université de Sherbrooke.
Can Fam Physician. 1996 Nov;42:2193-7.
To describe the evaluation of a program to improve the recording of drug prescribing in medical records. DESIGN: Experimental study with before and after measurements, without a control group, of the medical files of all patients who consulted during 2 different weeks, 9 months apart. SETTING: Family Medicine Unit of Centre hospitalier de l'Université Laval. PARTICIPANTS: Teachers and residents in the Family Medicine Unit. MAIN OUTCOME MEASURE: Proportion of prescriptions for drugs having a systemic effect (n = 206 for week before, n = 257 for week after) for which the following information was recorded: concentration, dosage, quantity prescribed or length of treatment, number of renewals. RESULTS: After the program, recording frequency increased from 86% to 97% for concentration, 80% to 95% for dosage, 52% to 79% for the quantity prescribed, and 20% to 71% for number of renewals. Both groups of doctors showed a notable improvement, except for the recording of quantity prescribed by residents, which remained stable. CONCLUSION: We observed an improvement in the recording of drug prescriptions in medical files. The program had a greater effect on teachers who had been exposed to activities that are known to be effective in improving recording.
描述一项旨在改善病历中药物处方记录的项目评估情况。
采用前后测量的实验性研究，无对照组，对相隔9个月的2个不同星期内就诊的所有患者的病历进行研究。
拉瓦尔大学中心医院家庭医学科。
家庭医学科的教师和住院医师。
有全身作用的药物处方（前一周n = 206，后一周n = 257）中记录以下信息的比例：浓度、剂量、处方数量或治疗时长、续方次数。
项目实施后，浓度的记录频率从86%提高到97%，剂量从80%提高到95%，处方数量从52%提高到79%，续方次数从20%提高到71%。两组医生均有显著改善，但住院医师的处方数量记录保持稳定。
我们观察到病历中药物处方记录有所改善。该项目对接触过已知能有效改善记录的活动的教师影响更大。
