RESUMO
A standardized system for recording patient care data for medical audit was developed and implemented in six community hospitals' coronary care units. It utilized the principles of predefining the data base and having both nurses and physicians participate. This system was compared with conventional retrospective record abstraction as a source of information for medical audit. The results suggest that the proposed system produces slightly more clinical data relevant to diagnostic impressions. Accuracy is comparable to that achieved by standard computerized abstraction procedures. Such an approach is readily adaptable for implementing medical audit to meet the requirements currently imposed upon community hospitals.
Assuntos
Unidades de Cuidados Coronarianos , Sistemas de Informação , Auditoria Médica , Administradores de Registros Médicos/estatística & dados numéricos , Prontuários Médicos/normas , Corpo Clínico Hospitalar/estatística & dados numéricos , Recursos Humanos de Enfermagem Hospitalar/estatística & dados numéricos , Estudos Prospectivos , Estudos RetrospectivosRESUMO
It has been argued that conversion of office records to the problem-oriented medical record entails a prohibitive cost in money and physician time. This study reports an evaluation of the cost of preparing problem lists from existing ambulatory patient records by non-physician personnel. The problem lists constructed by non-physician personnel were judged by physicians to be accurate, and the cost was much less than that required when physicians reviewed charts and prepared problem lists themselves. The method described here is an accurate and cost-effective way to begin conversion of outpatient records to P.O.M.R.
