[The medical record--content, interpretation and quality. Study of 100 medical records from a department of internal medicine].
An evaluation of the primary medical records of 100 patients admitted to a medical department showed that several elements in the journal often had been left out. Therefore all doctors working in the department were asked for their opinion of the necessity for each of the elements in a journal. A comparison of these doctors' opinions with our registrations indicated that the actual "shortening" of the journals was probably a result of choice rather than mere chance. Despite a considerable amount of work trying to establish relevant criteria, we did not succeed in developing a reliable method for measuring the quality of the medical record. The journals recorded at night were significantly shorter than those recorded during the day. A follow-up note (or discharge of the patient within one day), was found in 80% of the journals. Quality standards of the medical record are lacking and should be developed.
Solberg
E E
EE
Medisinsk klinikk, Ullevål sykehus, Oslo.
Aabakken
L
L
Sandstad
O
O
Bach-Gansmo
E
E
Nordby
G
G
Enger
E
E
Stene-Larsen
G
G
D005069:Evaluation Studies as Topic; D005500:Follow-Up Studies; D006801:Humans; D007388:Internal Medicine; D008499:Medical Records / Q000592:standards; D009664:Norway; D010343:Patient Admission; D010351:Patient Discharge; D011786:Quality Control
Journalen--innhold, forventning og kvalitet. En studie av 100 indremedisinske innkomstjournaler.