Margileth A M, Thompson H C, Osborne C E
Pediatrics. 1976 May;57(5):754-9.
During part of a national study to formulate criteria for chart audit of quality assurance of child health care, criteria were developed for diagnosis and management of urinary tract infections. These criteria were validated by pediatricians and family physicians in academic medicine and in practice. They were judged relevant to the medical care process and patient outcome by both. The selected criteria were also recommended by the majority of two large physician groups for use in peer review. An important aspect of the study assessed the frequency of performing and recording indicated procedures or tests. In the first three phases of the study these criteria were said to be performed and recorded by a large majority of physicians. However, in the fourth (community) phase, when charts of 166 primary care physicians were actually audited, documentation was so poor that peer review by chart audit would be impractical at present. Assuming proper documentation of the medical care process, similar criteria could be used for chart audit, clinical research, and educational purposes. Since the diagnostic and management process of initial urinary tract infection is established, development of structured health care forms and education in proper record-keeping are two important challenges for those interested in the evaluation of ambulatory care.
在一项旨在制定儿童保健质量保证图表审核标准的全国性研究的部分阶段，制定了尿路感染的诊断和管理标准。这些标准由学术医学领域和实际工作中的儿科医生和家庭医生进行了验证。他们都认为这些标准与医疗过程和患者预后相关。两个大型医生团体中的大多数也推荐选用这些标准用于同行评审。该研究的一个重要方面评估了执行和记录指定程序或检查的频率。在研究的前三个阶段，据说绝大多数医生都执行并记录了这些标准。然而，在第四阶段（社区阶段），当实际审核166名初级保健医生的图表时，记录情况非常糟糕，以至于目前通过图表审核进行同行评审是不切实际的。假设医疗过程有适当的记录，类似的标准可用于图表审核、临床研究和教育目的。由于初始尿路感染的诊断和管理过程已经确立，对于那些关注门诊护理评估的人来说，开发结构化的医疗保健表格和进行正确记录保存方面的教育是两项重要挑战。
