Kabir A, Hanson R, Mellis C M, van Asperen P P
Institute of Child and Mother Health, Dhaka, Bangladesh.
J Qual Clin Pract. 1998 Sep;18(3):187-93.
The documentation of acute asthma in written medical records was compared with data entered into a Computer-Assisted Triage System (CATS) in 104 children who presented to the emergency department and subsequently admitted to the Royal Alexandra Hospital for Children, Sydney. A total of 65 items in 5 categories were analysed and satisfactory documentation was defined as the recording of a specific item in more than 80% of records (written or electronic). Satisfactory documentation was observed for all 6 items in visit details and 9 out of 10 items in triage details for both recording systems. Nursing observations were better documented in the medical record than in CATS (87 vs 25%; kappa = 0.63). Documentation of medical details was also worse in CATS (75 vs 25%; kappa = 0.24) and the documentation of asthma severity was poor in both systems (31 vs 0%; kappa = 0.31). Attempts to improve asthma documentation through the development of a computerized medical record have highlighted further barriers to documentation.
对104名前往急诊科就诊并随后入住悉尼皇家亚历山德拉儿童医院的儿童的书面病历中急性哮喘的记录情况，与录入计算机辅助分诊系统（CATS）的数据进行了比较。分析了5个类别中的总共65项内容，将满意的记录定义为在超过80%的记录（书面或电子记录）中记录了特定项目。在两个记录系统中，就诊详情的所有6项以及分诊详情的10项中的9项都有满意的记录。护理观察在病历中的记录情况比在CATS中更好（87%对25%；kappa = 0.63）。医疗细节在CATS中的记录也较差（75%对25%；kappa = 0.24），并且两个系统中哮喘严重程度的记录都很差（31%对0%；kappa = 0.31）。通过开发计算机化病历试图改善哮喘记录情况，凸显了记录方面的进一步障碍。
