Methods Inf Med 2005; 44(05): 609-615
DOI: 10.1055/s-0038-1634016
Original Article
Schattauer GmbH

The Use of a Structured Form during Urology Out-patient Consultations

A Randomised Controlled Trial
K. Thomas
1   Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
,
M. Emberton
1   Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
2   Institute of Urology and Nephrology, University College London, London, UK
,
B. Reeves
1   Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
› Institutsangaben
Weitere Informationen

Publikationsverlauf

Received 21. Juli 2004

accepted: 25. Januar 2005

Publikationsdatum:
07. Februar 2018 (online)

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Summary

Objectives: To compare the completeness of documentation in the medical record using a structured form (SF) versus a traditional medical record (TMR).

Methods: Randomised controlled trial comparing the use of SF and TMR in urology out-patient clinics for documentation of 15 items of clinical information, time taken to complete and acceptability to clinicians assessed by a self-completion questionnaire. in a teaching and district general hospitals

Results: Four hundred new urology patient consultations, 11 clinicians. Completeness of information was compared between groups based on the medical record alone (SF vs. TMR), medical record plus letter to GP and letter alone. SFs were significantly (p<0.0001) more complete than TMRs for the majority of the items in all three groups. There was no significant difference in the time taken to document information using either type of record. The clinicians generally found the SF acceptable for routine use.

Conclusions: Structured forms significantly improved the completeness of documentation for new out-patient consultations in urology.