Steven I D, Coffey G A, Burgess T A, Bishop K, Mudge P
Calvary Hospital, North Adelaide, South Australia.
Aust Fam Physician. 1997 Jan;26 Suppl 1:S18-28.
To develop criteria to enable the monitoring of general practitioner (GP) case records using consensus guidelines for conditions commonly managed in general practice and to measure how well the case records of a non random sample of GPs conformed to these criteria.
An iterative process was used to develop criteria from consensus guidelines for 19 conditions. Criteria were also developed to enable monitoring of the structure and content of the patient case record. A non random sample of GPs in Adelaide was approached to allow measurement of the content of their case records against these criteria. This measurement was undertaken by allied health professionals. An overall percentage score of conformity with the criteria was created for 10 acute, and six chronic conditions and for the patient case record review. These were rank ordered and Kendall's rank order correlation coefficients were used to compare the results in these three areas of practice.
Criteria were successfully developed for each condition. Thirty-one GPs had their patient case records assessed. There was substantial variability between these practitioners in their conformity to the criteria. Kendall's rank order coefficients found statistically significant correlation between the results for acute and chronic conditions, and between acute conditions and the patient case record review section.
It is feasible to develop criteria that enable measurement of the conformity of GP case records to these criteria. The overall level of conformity, together with the substantial variability found between practitioners suggest that there is a need for GPs to address this area of their practice.
制定标准，以便使用全科医疗中常见病症的共识指南来监测全科医生（GP）的病例记录，并衡量一组非随机抽取的全科医生的病例记录符合这些标准的程度。
采用迭代过程，根据19种病症的共识指南制定标准。还制定了用于监测患者病例记录结构和内容的标准。研究人员联系了阿德莱德的一组非随机抽取的全科医生，以便根据这些标准衡量他们病例记录的内容。这项衡量工作由专职医疗专业人员进行。针对10种急性病症、6种慢性病症以及患者病例记录审查，创建了符合标准的总体百分比得分。对这些得分进行排序，并使用肯德尔等级相关系数来比较这三个实践领域的结果。
成功为每种病症制定了标准。对31名全科医生的患者病例记录进行了评估。这些从业者在符合标准方面存在很大差异。肯德尔等级系数发现，急性病症和慢性病症的结果之间，以及急性病症与患者病例记录审查部分的结果之间存在统计学上的显著相关性。
制定能够衡量全科医生病例记录符合这些标准程度的标准是可行的。总体符合水平以及从业者之间存在的巨大差异表明，全科医生需要关注其执业的这一领域。
