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首页> 美国卫生研究院文献>The British Journal of General Practice >To what extent do clinical notes by general practitioners reflect actual medical performance? A study using simulated patients.
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To what extent do clinical notes by general practitioners reflect actual medical performance? A study using simulated patients.

机译：全科医生的临床笔记在多大程度上反映了实际的医疗表现？使用模拟患者的研究。

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BACKGROUND. Review of clinical notes is used extensively as an indirect method of assessing doctors' performance. However, to be acceptable it must be valid. AIM. This study set out to examine the extent to which clinical notes in medical records of general practice consultations reflected doctors' actual performance during consultations. METHOD. Thirty nine general practitioners in the Netherlands were consulted by four simulated patients who were indistinguishable from real patients and who reported on the consultations. The complaints presented by the simulated patients were tension headache, acute diarrhoea and pain in the shoulder, and one presented for a check up for non-insulin dependent diabetes. Later, the doctors forwarded their medical records of these patients to the researchers. Content of consultations was measured against accepted standards for general practice and then compared with content of clinical notes. An index, or content score, was calculated as the measure of agreement between actions which had actually been recorded and actions which could have been recorded in the clinical notes. A high content score reflected a consultation which had been recorded well in the medical record. The correlation between number of actions across the four complaints recorded in the clinical notes and number of actions taken during the consultations was also calculated. RESULTS. The mean content score (interquartile range) for the four types of complaint was 0.32 (0.27-0.37), indicating that of all actions undertaken, only 32% had been recorded. However, mean content scores for the categories 'medication and therapy' and 'laboratory examination' were much higher than for the categories 'history' and 'guidance and advice' (0.68 and 0.64, respectively versus 0.29 and 0.22, respectively). The correlation between number of actions across the four complaints recorded in the clinical notes and number of actions taken during the consultations was 0.54 (P < 0.05). CONCLUSION. The use of clinical notes to audit doctors' performance in Dutch general practice is invalid. However, the use of clinical notes to rank doctors according to those who perform many or a few actions in a consultation may be justified.
机译：背景。临床笔记的审查被广泛用作评估医生绩效的间接方法。但是，要被接受，它必须是有效的。目标。这项研究着手检查全科诊症医疗记录中的临床笔记在多大程度上反映了医生在诊症中的实际表现。方法。四名模拟患者与荷兰的三十九名全科医生进行了会面，他们与真实患者没有区别，并在会诊中进行了报告。模拟患者的主诉为紧张性头痛，急性腹泻和肩部疼痛，其中一名主诉为检查非胰岛素依赖型糖尿病。后来，医生将这些患者的病历转发给研究人员。会诊的内容是根据公认的通用标准衡量的，然后与临床笔记的内容进行比较。计算指数或内容分数，作为实际记录的动作与临床记录中可能记录的动作之间一致性的度量。较高的分数反映了在医疗记录中已很好记录的咨询。还计算了临床记录中记录的四个主诉中的行动次数与会诊期间采取的行动次数之间的相关性。结果。四种投诉类型的平均内容得分（四分位数范围）为0.32（0.27-0.37），表明在所有已采取的行动中，只有32％被记录。但是，“药物和治疗”和“实验室检查”类别的平均内容得分远高于“历史”和“指导和建议”类别（分别为0.68和0.64，分别为0.29和0.22）。临床笔记中记录的四个投诉中的行动数量与会诊期间采取的行动数量之间的相关性是0.54（P <0.05）。结论。在荷兰的一般实践中，使用临床笔记来审核医生的表现是无效的。但是，使用临床笔记根据在咨询中执行很多或几次动作的医生对医生进行排名可能是合理的。

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