[Number of diagnoses in the final report and in the medical record].
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.
Osterwalder
P
P
Departement für Innere Medizin, Medizinische Poliklinik, Universitätsspital Zürich.
Vetter
W
W
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003625:Data Collection; D003933:Diagnosis; D004282:Documentation / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008499:Medical Records / Q000706:statistics & numerical data*; D008875:Middle Aged; D010044:Outpatient Clinics, Hospital / Q000706:statistics & numerical data; D011785:Quality Assurance, Health Care; D013557:Switzerland