Madlon-Kay D J
Department of Family and Community Medicine, St Paul Ramsey Medical Center, MN, USA.
Arch Fam Med. 1998 Sep-Oct;7(5):480-3. doi: 10.1001/archfami.7.5.480.
To determine if a structured encounter form for well-child care improves documentation of well-child care.
Retrospective medical record review of a before-and-after trial.
Family practice residency clinic serving a primarily low-socioeconomic urban population.
Children younger than 6 years receiving well-child care visits.
Detailed checklists were developed and implemented in 1994 for each of 12 well-child examinations for the assessment of children aged 2 weeks to 5 years based on recommendations from the American Academy of Pediatrics and the US Preventive Services Task Force.
Documentation of multiple aspects of well-child care, including developmental assessment, safety and nutrition counseling, and laboratory tests for 6-month periods in 1993 and 1994, before and after implementation of the structured encounter form.
A total of 842 well-child visits were reviewed. Documentation improved significantly with the use of the encounter form for 19 of the 23 aspects of well-child care that were studied. Screening test rates were less than optimal despite the encounter form.
The structured encounter form was very effective in improving documentation of almost all aspects of well-child care. However, effective communication is needed among physicians, nurses, and parents to ensure optimal screening test rates.
确定用于儿童健康保健的结构化问诊表是否能改善儿童健康保健的记录。
一项前后试验的回顾性病历审查。
主要为社会经济地位较低的城市人口服务的家庭医学住院医师诊所。
接受儿童健康保健访视的6岁以下儿童。
根据美国儿科学会和美国预防服务工作组的建议，1994年为针对2周龄至5岁儿童的12次儿童健康检查中的每一次制定并实施了详细的检查表。
在结构化问诊表实施前后，1993年和1994年6个月期间儿童健康保健多个方面的记录，包括发育评估、安全和营养咨询以及实验室检查。
共审查了842次儿童健康访视。在所研究的儿童健康保健的23个方面中，有19个方面使用问诊表后记录有显著改善。尽管有问诊表，筛查测试率仍未达到最佳水平。
结构化问诊表在改善儿童健康保健几乎所有方面的记录方面非常有效。然而，医生、护士和家长之间需要进行有效的沟通，以确保达到最佳的筛查测试率。
