Kiernan W E, McCreadie R G, Flanagan W L
Br J Psychiatry. 1976 Aug;129:167-72. doi: 10.1192/bjp.129.2.167.
An assessment was made of 100 case records written by junior medical staff working in a psychiatric teaching hospital. Thirty-nine items were rated, and considerable gaps were found in the records. The Mental State was more poorly recorded than the History; the Formulation and Summary were more satisfactory. Possible reasons for the findings are discussed, including methodological difficulties, administrative considerations, and attitudes of junior staff. The implications for the training and assessment of junior psychiatrists are explored.
对一家精神病教学医院初级医务人员撰写的100份病例记录进行了评估。对39项内容进行了评分，发现记录中存在相当大的差距。精神状态记录比病史记录更差；诊断和总结更令人满意。讨论了这些发现的可能原因，包括方法上的困难、行政方面的考虑以及初级工作人员的态度。探讨了对初级精神科医生培训和评估的影响。
