Osterwalder P, Vetter W
Departement für Innere Medizin, Medizinische Poliklinik, Universitätsspital Zürich.
Praxis (Bern 1994). 1998 Dec 10;87(50):1749-51.
One hundred patient records of an internistic outpatient clinic were evaluated retrospectively for differences regarding the number of diagnoses in the documentation and the final report. Whereas the final or interim reports on the average contained 2.8 clinically relevant diagnoses, screening of the total documentation let the number rise to 3.5. Mainly the reports qualified as qualitatively poor led to overlooked or neglected relevant findings. Our results underline the importance of a meticulously kept medical record for a medical practice of high standards and responsibility.
对一家内科门诊诊所的100份患者记录进行了回顾性评估，以分析病历记录和最终报告中诊断数量的差异。最终报告或中期报告平均包含2.8个临床相关诊断，而对全部病历记录进行筛查后，这一数字升至3.5个。主要是那些质量较差的报告导致相关发现被忽视或遗漏。我们的结果强调了一份精心保存的病历对于高标准、负责任的医疗实践的重要性。
